**9. Medico-legal, reputational, and regulatory implications of ORF**

Additional consequences of ORFs, above and beyond direct patient harm, include serious medico-legal repercussions, financial costs, and severe reputational damage to both involved providers and their institutions [79, 80]. Moreover, such events inculcate mistrust toward the healthcare system among the public [80]. Although the majority of patients who sustain medical injury do not file lawsuits, the medical system is riddled with an abundance of frivolous claims, the cost of which is not trivial [81–84]. It has also been noted that lack of provider awareness, combined with inadequate levels of communication, may result in elevated malpractice risk [85]. The development of appropriate internal reporting mechanisms and educational programs may help mitigate the overall legal risk associated with adverse events, including ORFs [85, 86]. Factors known to prevent litigation by patients who suffered complications include excellent surgeon-patient relationship, full and honest disclosure, and effective communication between patients, providers, and teams [87, 88].

Consequences of unusual or elevated incidence of ORFs can be significant, up to and including mandatory closure of operative suites at an institution [2]. Consequently, thorough assessment of risks, institutional protocols, and employee competency in this critical area is mandatory [2]. Regular (e.g., quarterly) fire drills may help reinforce the knowledge of essential patient safety protocols and serve to refresh key information among the OR staff [89].
