Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles
ilustraciones, gráficas, tablas
- Autores:
-
Rodríguez De Narváez, Juan Francisco
- Tipo de recurso:
- Fecha de publicación:
- 2022
- Institución:
- Universidad Nacional de Colombia
- Repositorio:
- Universidad Nacional de Colombia
- Idioma:
- spa
- OAI Identifier:
- oai:repositorio.unal.edu.co:unal/80896
- Palabra clave:
- 610 - Medicina y salud::617 - Cirugía, medicina regional, odontología, oftalmología, otología, audiología
Preoperative Care
Anesthesia Department, Hospital
Case-Control Studies
Cuidados Preoperatorios
Servicio de Anestesia en Hospital
Estudios de Casos y Controles
Cancelación quirúrgica
Evaluación preoperatoria
Procedimientos quirúrgicos electivos
Surgery cancellation
Surgical clearance
Elective surgical procedures
- Rights
- openAccess
- License
- Atribución-NoComercial 4.0 Internacional
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Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles |
| dc.title.translated.eng.fl_str_mv |
Identification of clinical factors associated with surgical cancellation in the preoperative evaluation in a University Hospital in the city of Bogota. A case-control study |
| title |
Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles |
| spellingShingle |
Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles 610 - Medicina y salud::617 - Cirugía, medicina regional, odontología, oftalmología, otología, audiología Preoperative Care Anesthesia Department, Hospital Case-Control Studies Cuidados Preoperatorios Servicio de Anestesia en Hospital Estudios de Casos y Controles Cancelación quirúrgica Evaluación preoperatoria Procedimientos quirúrgicos electivos Surgery cancellation Surgical clearance Elective surgical procedures |
| title_short |
Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles |
| title_full |
Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles |
| title_fullStr |
Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles |
| title_full_unstemmed |
Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles |
| title_sort |
Identificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controles |
| dc.creator.fl_str_mv |
Rodríguez De Narváez, Juan Francisco |
| dc.contributor.advisor.spa.fl_str_mv |
Valero Bernal, José Francisco |
| dc.contributor.author.spa.fl_str_mv |
Rodríguez De Narváez, Juan Francisco |
| dc.subject.ddc.spa.fl_str_mv |
610 - Medicina y salud::617 - Cirugía, medicina regional, odontología, oftalmología, otología, audiología |
| topic |
610 - Medicina y salud::617 - Cirugía, medicina regional, odontología, oftalmología, otología, audiología Preoperative Care Anesthesia Department, Hospital Case-Control Studies Cuidados Preoperatorios Servicio de Anestesia en Hospital Estudios de Casos y Controles Cancelación quirúrgica Evaluación preoperatoria Procedimientos quirúrgicos electivos Surgery cancellation Surgical clearance Elective surgical procedures |
| dc.subject.decs.eng.fl_str_mv |
Preoperative Care Anesthesia Department, Hospital Case-Control Studies |
| dc.subject.decs.spa.fl_str_mv |
Cuidados Preoperatorios Servicio de Anestesia en Hospital Estudios de Casos y Controles |
| dc.subject.proposal.spa.fl_str_mv |
Cancelación quirúrgica Evaluación preoperatoria Procedimientos quirúrgicos electivos |
| dc.subject.proposal.eng.fl_str_mv |
Surgery cancellation Surgical clearance Elective surgical procedures |
| description |
ilustraciones, gráficas, tablas |
| publishDate |
2022 |
| dc.date.accessioned.none.fl_str_mv |
2022-02-07T18:40:44Z |
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2022-02-07T18:40:44Z |
| dc.date.issued.none.fl_str_mv |
2022-02-04 |
| dc.type.spa.fl_str_mv |
Trabajo de grado - Especialidad Médica |
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info:eu-repo/semantics/masterThesis |
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info:eu-repo/semantics/acceptedVersion |
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Text |
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http://purl.org/redcol/resource_type/TM |
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acceptedVersion |
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https://repositorio.unal.edu.co/handle/unal/80896 |
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Universidad Nacional de Colombia |
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Repositorio Institucional Universidad Nacional de Colombia |
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https://repositorio.unal.edu.co/ |
| url |
https://repositorio.unal.edu.co/handle/unal/80896 https://repositorio.unal.edu.co/ |
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Universidad Nacional de Colombia Repositorio Institucional Universidad Nacional de Colombia |
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spa |
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Bireme |
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Muñoz-Caicedo, A., Perlaza-Cuero, L. A. & Burbano-Álvarez, V. A. Causas de cancelación de cirugía programada en una clínica de alta complejidad de Popayán, Colombia. Rev. Fac. Med. 67, 17–21 (2019). Da’ar, O. B. & Al-Mutairi, T. How do patient demographics, time-related variables, reasons for cancellation, and clinical procedures affect frequency of same-day operating room surgery cancelation? A maximum likelihood method. BMC Health Serv Res 18, 454 (2018). Desta, M. et al. Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia. Patient Saf Surg 12, 25 (2018). Luo, L., Liu, C., Feng, L., Zhao, S. & Gong, R. A random forest and simulation approach for scheduling operation rooms: Elective surgery cancelation in a Chinese hospital urology department. Int J Health Plann Mgmt 33, 941–966 (2018). Hovlid, E. & Bukve, O. A qualitative study of contextual factors’ impact on measures to reduce surgery cancellations. BMC Health Serv Res 14, 215 (2014). Spratt, B., Kozan, E. & Sinnott, M. Analysis of uncertainty in the surgical department: durations, requests and cancellations. Aust. Health Review 43, 706 (2019). Ministerio de Salud y Protección Social. Resolucion 256 de 2016. Muñoz, L. et al. Cancelación de procedimientos electivos y su relación con la valoración preanestésica. Repert. Med. Cir. 27, 24–29 (2018). González Avellaneda, A. del P. Costos de no calidad por la cancelación de cirugías en una clínica privada de Bogotá D.C. Colombia. Cuader. Lat. Admon. 11, 17 (2016). Dominguez Lozano, B. S., Ortega Crespo, G., Díaz Pérez, A. & Broullon Dobarro, A. Incidencias y causas de la cancelación de cirugía en un hospital universitario, Barranquilla, Colombia 2016: Incidences and Causes of Surgery Cancellation in a University Hospital in Barranquilla, Colombia, in 2016t. Enf Global 19, 507–526 (2019). Muñoz-Caicedo, A., Sarmiento, C. P. & Torres, M. S. Cancelación de cirugía programada en una institución de III nivel de atención. Rev. Fac. Cienc. Salud Univ. Cauca 13, 10–15 (2011). INFORME DE GESTION DE CIRUGIA DICIEMBRE 2019 HOSPITAL UNIVERSITARIO NACIONAL. (2020). Al Talalwah, N. & McIltrot, K. H. Cancellation of Surgeries: Integrative Review. Journal of PeriAnesthesia Nursing 34, 86–96 (2019). Dell’Atti, L. The Cancelling of Elective Surgical Operations Causes Emotional Trauma and a Lack of Confidence: Study from a Urological Department. Urologia Journal 81, 242–245 (2014). Lee, D. J., Ding, J. & Guzzo, T. J. Improving Operating Room Efficiency. Curr Urol Rep 20, 28 (2019). Charlesworth, M. & Pandit, J. J. Rational performance metrics for operating theatres, principles of efficiency, and how to achieve it: Efficiency and productivity of operating theatres. Br J Surg 107, e63–e69 (2020). Turunen, E., Miettinen, M., Setälä, L. & Vehviläinen-Julkunen, K. Financial cost of elective day of surgery cancellations. JHA 7, 30 (2018). Prin, M., Eaton, J., Mtalimanja, O. & Charles, A. High Elective Surgery Cancellation Rate in Malawi Primarily Due to Infrastructural Limitations. World J Surg 42, 1597–1602 (2018). Broullón Dobarro, A. et al. Análisis retrospectivo de las suspensiones quirúrgicas y de los factores influyentes durante 8 años. Cirugía Española 97, 213–221 (2019). Tostes, M. F. do P., Covre, E. R. & Fernandes, C. A. M. Access to surgical assistance: challenges and perspectives. Rev. Latino-Am. Enfermagem 24, (2016). Olguín-Juárez, P. El análisis factorial para aumentar el rendimiento del quirófano y disminuir la cancelación de cirugía electiva. Cirujano general 40, 78–86 (2018). Al Talalwah, N., McIltrot, K. H. & Al Ghamdi, A. Elective Surgical Cancellations in a Tertiary Hospital in the Middle East: Quality Improvement Process. Journal of PeriAnesthesia Nursing 34, 310–321 (2019). Denholm, L., Lal, A., Henderson, M. & McConnell, P. Bioethics: cancelling patient operations. Current Opinion in Anaesthesiology 33, 211–217 (2020). Miri Bonjar, M. et al. Impact of the Health Transformation Plan on the Number of Surgical Operations and Their Cancelation. INQUIRY 56, 004695801984638 (2019). Guillén, J. M. et al. Cancelación en CMA: Incidencia y causas. Cirugía Española 90, 429–433 (2012). Ferschl, M. B., Tung, A., Sweitzer, B., Huo, D. & Glick, D. B. Preoperative Clinic Visits Reduce Operating Room Cancellations and Delays: Anesthesiology 103, 855–859 (2005). Olson, R. P. & Dhakal, I. B. Day of surgery cancellation rate after preoperative telephone nurse screening or comprehensive optimization visit. Perioper Med 4, 12 (2015). Gaucher, S. et al. Assessment of a Standardized Pre-Operative Telephone Checklist Designed to Avoid Late Cancellation of Ambulatory Surgery: The AMBUPROG Multicenter Randomized Controlled Trial. PLoS ONE 11, e0147194 (2016). Haufler, K. & Harrington, M. Using Nurse-to-Patient Telephone Calls to Reduce Day-of-Surgery Cancellations. AORN Journal 94, 19–26 (2011). Huynh, E. et al. Can the number of surgery delays and postponements due to unavailable instrumentation be reduced? Evaluating the benefits of enhanced collaboration between the sterilization and orthopedic surgery units. Orthopaedics & Traumatology: Surgery & Research 105, 563–568 (2019). Stewart, J. J., Fayed, I., Henault, S., Kalantar, B. & Voyadzis, J.-M. Use of a Smartphone Application for Spine Surgery Improves Patient Adherence with Preoperative Instructions and Decreases Last-minute Surgery Cancellations. Cureus 11(3):e4192 (2019). Gheysari, E., Yousefi, H., Soleymani, H. & Mojdeh, S. Effect of six sigma program on the number of surgeries cancellation. Iranian J Nursing Midwifery Res 21, 191 (2016). Tan, A. L. et al. Risk factors and reasons for cancellation within 24 h of scheduled elective surgery in an academic medical centre: A cohort study. International Journal of Surgery 66, 72–78 (2019). Luo, L. et al. Machine learning for identification of surgeries with high risks of cancellation. Health Informatics Journal 26, 141–155 (2020). Peduzzi, P., Concato, J., Kemper, E., Holford, T. R. & Feinstein, A. R. A simulation study of the number of events per variable in logistic regression analysis. Journal of Clinical Epidemiology 49, 1373–1379 (1996). Emanuel, A. & Macpherson, R. The Anaesthetic Pre-Admission Clinic is Effective in Minimising Surgical Cancellation Rates. Anaesth Intensive Care 41, 90–94 (2013). Jones, N. How COVID-19 is changing the cold and flu season. Nature 588, 388–390 (2020). Ausset, S., Bouaziz, H., Brosseau, M., Kinirons, B. & Benhamou, D. Improvement of information gained from the pre-anaesthetic visit through a quality-assurance programme. British Journal of Anaesthesia 88, 280–283 (2002). Shahzad, S., Younas, T. & Khan, E.-D. Clinical audit on quality of preanesthesia evaluation. APIC 25, 15–20 (2021). Mokgwathi, G., Baloyi, B. & Ogunbanjo, G. An audit of preoperative evaluation of general surgery patients at Dr George Mukhari Hospital. Southern African Journal of Anaesthesia and Analgesia 17, 177–180 (2011). Swart, W. & Kuhn, A. An audit of documented preoperative evaluation of surgery patients at Universitas Academic Hospital, Bloemfontein. Southern African Journal of Anaesthesia and Analgesia 21, 107–112 (2015). Abeldaño, R. A. & Coca, S. M. Tasas y causas de suspensión de cirugías en un hospital público durante el año 2014. Enfermería Universitaria 13, 107–113 (2016). Unger, T. et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 75, 1334–1357 (2020). Leite, K. A., Hobgood, T., Hill, B. & Muckler, V. C. Reducing Preventable Surgical Cancellations: Improving the Preoperative Anesthesia Interview Process. Journal of PeriAnesthesia Nursing 34, 929–937 (2019). Lee, A., Kerridge, R. K., Chui, P. T., Chiu, C. H. & Gin, T. Perioperative Systems as a quality model of perioperative medicine and surgical care. Health Policy 102, 214–222 (2011). Yu, K., Xie, X., Luo, L. & Gong, R. Contributing factors of elective surgical case cancellation: a retrospective cross-sectional study at a single-site hospital. BMC Surg 17, 100 (2017). Cho, H.-S., Lee, Y., Lee, S., Kim, J. & Kim, T. Reasons for Surgery Cancellation in a General Hospital: A 10-year Study. IJERPH 16, 7 (2018). Wong, D. J. N., Harris, S. K. & Moonesinghe, S. R. Cancelled operations: a 7-day cohort study of planned adult inpatient surgery in 245 UK National Health Service hospitals. British Journal of Anaesthesia 121, 730–738 (2018). Solak, A. et al. Elective Case Cancellation on the Day of Surgery at a General Hospital in Sarajevo: Causes and Possible Solutions. Mater Sociomed 31, 49 (2019). Roxbury, C. R. et al. Analysis of 24-hour surgical cancellations in an academic rhinology and skull base surgery practice: Cancellations in rhinology. Int Forum Allergy Rhinol. 9, 298–304 (2019). Ahmed, T., Khan, M. & Khan, F. A. Cancellation of surgery in patients attending the preoperative anaesthesia assessment clinic: a prospective audit. J Pak Med Assoc 59, 547–550 (2009). Leslie, R. J., Beiko, D., van Vlymen, J. & Siemens, D. R. Day of surgery cancellation rates in urology: Identification of modifiable factors. CUAJ (2012) doi:10.5489/cuaj.12020. Abeeleh, M. A. et al. Reasons for operation cancellations at a teaching hospital: prioritizing areas of improvement. Ann Surg Treat Res 93, 65 (2017). Fayed, A., Elkouny, A., Zoughaibi, N. & Wahabi, H. Elective surgery cancelation on day of surgery: An endless dilemma. Saudi J Anaesth 10, 68 (2016). Barbosa, M. H., Miranda Goulart, D. M., Vieira de Andrade, E. & Mattia, A. L. de. Análisis de la suspensión de cirugía en un hospital docente. Enferm. glob. 11, 164–173 (2012). de Lorenzo-Pinto, A. et al. Cancellations of elective surgical procedures due to inadequate management of chronic medications. J Clin Pharm Ther 44, 561–564 (2019). Lankoande, M. et al. Cancellation of elective surgical procedures in the university teaching hospital center Yalgado Ouedraogo in Burkina Faso: incidence, reasons and proposals for improvement. Southern African Journal of Anaesthesia and Analgesia 22, 140–144 (2016). |
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Universidad Nacional de Colombia |
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Bogotá - Medicina - Especialidad en Anestesiología y Reanimación |
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Departamento de Cirugía |
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Facultad de Medicina |
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Bogotá, Colombia |
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Universidad Nacional de Colombia - Sede Bogotá |
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Atribución-NoComercial 4.0 Internacionalhttp://creativecommons.org/licenses/by-nc/4.0/info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2Valero Bernal, José Franciscoba702cb17ce7bc319d6da28abeaa27e2Rodríguez De Narváez, Juan Franciscoff4a7d0b18e1b59121cc5cd8049f33e32022-02-07T18:40:44Z2022-02-07T18:40:44Z2022-02-04https://repositorio.unal.edu.co/handle/unal/80896Universidad Nacional de ColombiaRepositorio Institucional Universidad Nacional de Colombiahttps://repositorio.unal.edu.co/ilustraciones, gráficas, tablasLa cancelación el día de la cirugía es frecuente, genera costos, retrasa la atención y deteriora la salud de los pacientes. En nuestro medio no se ha evaluado la capacidad de la valoración preanestésica de identificar el riesgo de cancelación quirúrgica. Nuestro objetivo fue identificar factores en la consulta preanestésica capaces de predecir la cancelación por causa médica. Realizamos un estudio de Casos y Controles, identificamos los procedimientos ambulatorios durante el 2019 en el Hospital Universitario Nacional de Colombia cancelados por causa médica donde comparamos la valoración preanestésica de los procedimientos cancelados y los que no. Dividimos la muestra en un conjunto de entrenamiento y de validación, y mediante un modelo de regresión logística identificamos factores asociados a cancelación, se evaluó la capacidad predictiva de los dos conjuntos de datos. Se incluyeron 390 pacientes, las cancelaciones por causa médica representaron el 36.4% de las ambulatorias. La cirugías vasculares y maxilofaciales, el consumo de hipoglucemiantes, antiagregantes y anticoagulantes fueron identificados como factores independientes asociados a cancelación (p <0.05). El AUC para la muestra de entrenamiento y validación fue de 0.800 [95%IC: 0.734 a 0.866] y 0.675 [95%IC: 0.492 a 0.856], con un rendimiento predictivo similar (p: 0.209), para el punto de corte utilizado, obtuvimos una precisión de 76.43% y 82.42%, con un VPP del 45.12% y 50% y una sensibilidad de 63.79% y 50.00%. Aunque logramos identificar factores independientes asociados a cancelación, el modelo multivariado logístico estimado no es adecuado para predecir específicamente las cirugías ambulatorias canceladas por causa médica. (Texto tomado de la fuente).Cancellation on the day of surgery is frequent, generates costs, delays medical care and deteriorates patients’ health. The ability of preoperative evaluation to identify the risk of surgical cancellation has not been evaluated in our environment yet. Our objective was to identify factors capable of predicting medical cancellation in the pre-anesthetic consultation. We conducted a case-control study, and identified the outpatient procedures cancelled for medical reasons during 2019 at the Hospital Universitario Nacional de Colombia, comparing the pre-anesthetic evaluation of cancelled and performed procedures. We divided our sample into a group of training and validation, and using a logistic regression model we were able to identify factors related with cancellation, and after that we could evaluate the predictive capacity of the two groups. A total of 390 patients were included, cancellations due to medical reasons represented 36.4% of outpatient surgeries. Vascular and maxillofacial surgeries, hypoglycemic, antiplatelet and anticoagulant medication consumption were identified as factors associated with cancellation (p <0.05). The AUC for the training and validation sample was 0.800 [95% CI: 0.734 to 0.866] and 0.675 [95% CI: 0.492 to 0.856], with a similar predictive performance (p: 0.209), for the cut-off point used, an accuracy of 76.43% and 82.42% was obtained, with a PPV of 45.12% and 50% and a sensitivity of 63.79% and 50.00%. We were able to identify independent factors associated with cancellation, the estimated multivariate logistic model is not adequate to specifically predict outpatient surgeries cancelled for medical reasons.Incluye anexosEspecialidades MédicasEspecialista en Anestesiología y ReanimaciónMedicina perioperatoria y evaluación preanestésicaxiii, 38 páginasapplication/pdfspaUniversidad Nacional de ColombiaBogotá - Medicina - Especialidad en Anestesiología y ReanimaciónDepartamento de CirugíaFacultad de MedicinaBogotá, ColombiaUniversidad Nacional de Colombia - Sede Bogotá610 - Medicina y salud::617 - Cirugía, medicina regional, odontología, oftalmología, otología, audiologíaPreoperative CareAnesthesia Department, HospitalCase-Control StudiesCuidados PreoperatoriosServicio de Anestesia en HospitalEstudios de Casos y ControlesCancelación quirúrgicaEvaluación preoperatoriaProcedimientos quirúrgicos electivosSurgery cancellationSurgical clearanceElective surgical proceduresIdentificación en la consulta preanestésica, de factores clínicos asociados a cancelación quirúrgica en un Hospital Universitario en la ciudad de Bogotá. Un estudio de casos y controlesIdentification of clinical factors associated with surgical cancellation in the preoperative evaluation in a University Hospital in the city of Bogota. A case-control studyTrabajo de grado - Especialidad Médicainfo:eu-repo/semantics/masterThesisinfo:eu-repo/semantics/acceptedVersionTexthttp://purl.org/redcol/resource_type/TMBogotáBiremeMuñoz-Caicedo, A., Perlaza-Cuero, L. A. & Burbano-Álvarez, V. A. Causas de cancelación de cirugía programada en una clínica de alta complejidad de Popayán, Colombia. Rev. Fac. Med. 67, 17–21 (2019).Da’ar, O. B. & Al-Mutairi, T. How do patient demographics, time-related variables, reasons for cancellation, and clinical procedures affect frequency of same-day operating room surgery cancelation? A maximum likelihood method. BMC Health Serv Res 18, 454 (2018).Desta, M. et al. Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia. Patient Saf Surg 12, 25 (2018).Luo, L., Liu, C., Feng, L., Zhao, S. & Gong, R. A random forest and simulation approach for scheduling operation rooms: Elective surgery cancelation in a Chinese hospital urology department. Int J Health Plann Mgmt 33, 941–966 (2018).Hovlid, E. & Bukve, O. A qualitative study of contextual factors’ impact on measures to reduce surgery cancellations. BMC Health Serv Res 14, 215 (2014).Spratt, B., Kozan, E. & Sinnott, M. Analysis of uncertainty in the surgical department: durations, requests and cancellations. Aust. Health Review 43, 706 (2019).Ministerio de Salud y Protección Social. Resolucion 256 de 2016.Muñoz, L. et al. Cancelación de procedimientos electivos y su relación con la valoración preanestésica. Repert. Med. Cir. 27, 24–29 (2018).González Avellaneda, A. del P. Costos de no calidad por la cancelación de cirugías en una clínica privada de Bogotá D.C. Colombia. Cuader. Lat. Admon. 11, 17 (2016).Dominguez Lozano, B. S., Ortega Crespo, G., Díaz Pérez, A. & Broullon Dobarro, A. Incidencias y causas de la cancelación de cirugía en un hospital universitario, Barranquilla, Colombia 2016: Incidences and Causes of Surgery Cancellation in a University Hospital in Barranquilla, Colombia, in 2016t. Enf Global 19, 507–526 (2019).Muñoz-Caicedo, A., Sarmiento, C. P. & Torres, M. S. Cancelación de cirugía programada en una institución de III nivel de atención. Rev. Fac. Cienc. Salud Univ. Cauca 13, 10–15 (2011).INFORME DE GESTION DE CIRUGIA DICIEMBRE 2019 HOSPITAL UNIVERSITARIO NACIONAL. (2020).Al Talalwah, N. & McIltrot, K. H. Cancellation of Surgeries: Integrative Review. Journal of PeriAnesthesia Nursing 34, 86–96 (2019).Dell’Atti, L. The Cancelling of Elective Surgical Operations Causes Emotional Trauma and a Lack of Confidence: Study from a Urological Department. Urologia Journal 81, 242–245 (2014).Lee, D. J., Ding, J. & Guzzo, T. J. Improving Operating Room Efficiency. 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