Anita Amini - Graduated from the Department of Industrial Engineering, Islamic Azad University, Malayer Branch, Malayer, Hamadan, Iran
Mohammad Mehdi Sepehri - Professor of the Department of Industrial Engineering, Tarbiat Modares University, Tehran, Tehran, Iran

Various studies conducted in the world and Iran have shown that the issue of patient safety is one of the most important concerns of health care systems. Lack of safety and errors in the patient care system are the main concerns of the patient when receiving health services. Reducing avoidable injuries to patients should be a major concern of the health system. In this regard, the use of a systemic approach to investigate errors and make appropriate decisions to prevent their occurrence in the field of health and treatment has been approved. The method deals with network analysis of fuzzy process and radical analysis of cause (s) of case type. The method of data collection was direct observation, interview and review of documents. Super desision software was used to analyze the data. In the data analysis section, ۱۴ types of important errors have been selected. In the ranking of errors, medical error was selected as the most important errors. The patient's head and neck, spinelectomy during partial nephrectomy and the patient's arest during catheterization were selected as the most important medical errors. Lack of a general protocol for the anesthesia team, non-uniform temperature of the operating room, lack of pre-up room, long shifts for staff and high fatigue and lack of technical specialist (medical engineering) in the operating room are important causes of errors in this operating room.

Process network analysis, root cause analysis (cause), operating room errors