Factors Disrupting the Preference Card Management Process: A Root Cause Analysis

Preference cards, the nexus of an efficient OR, help ensure that OR personnel have what they need to safely and efficiently care for surgical patients. In June 2013, a new electronic health record (EHR) was implemented in the ORs of the Duke University Health System, Durham, North Carolina. Although it was an integrated system, the EHR disrupted supply management in the OR, which affected the availability of correct resources. The project team performed a process-improvement project using root cause analysis (RCA) to identify the factors that led to the disruption in the preference card management process for orthopedic surgical procedures. Team members identified that a chief cause of resource disruption was the mistiming of interface messages that created the pick lists and requisition forms. Based on the results of the RCA, the project team developed and implemented recommendations for process improvement.