There is considerable variation in the rate of and reasons for cancellations on the day of surgery, depending on the national healthcare service structure and individual hospital policies and management practices. This study aimed to investigate the main reasons for the cancellation of elective procedures and provide appropriate recommendations to reduce the rate of such avoidable cancellations and optimize the use of manpower and resources. The cancellation rate on surgery day for elective procedures in all fields was 6.3%. The highest cancellation rate was related to minor surgeries (19%), followed by urology (8%), pediatrics (7%), and plastic surgery (7%). The most common reasons for cancellation were patients not suitable for the procedure (37%), followed by patients who did not follow instructions (10%), lack of time (10.5%), and equipment/supplies problems (10%), and refusal to consent (6%). Our findings are inconsistent with studies conducted in St. Paul’s Hospital, Addis Ababa (8.9%) [12], Saudi Arabia (7.6%) [13], Brazil (6.8%) [14], and Wales (7.6%) [15], also lower than studies conducted in Sudan (20.2%) [16], Nigeria (20.2%) [17], Germany (12.7%) [18], New Delhi (17.6%) [19], and India (16.49%) [20]. In our research, the rate of cancellation was high in internal surgeries (minor surgery, e.g., intravascular catheter insertion, endoscopy, taking a biopsy, etc. (19%), followed by urology (8%), pediatric (7%), and plastic surgeries (7%). These variations may be explained by the national healthcare service’s structure, individual hospital policies, and management practices. Although there is a well-established pre-assessment service in the study hospital and pre‑anesthetic clinic, the most common reason for cancellation on the surgery day was that the patient was medically unfit for the operation. Some of the reasons identified were disagreement between the outcome at pre-assessment and the opinion of the anesthesiologist in charge on the day of the operation, the deterioration of the patient’s condition between pre-assessment and the operation day, and abnormal laboratory results detected after admission.

Previously, it has been reported that pre-assessment of the patient 30 days before surgery is not associated with a reduction in the volume of cancellations compared to pre-assessment 24 h before surgery [21]. If the health status of patients is assessed too early before surgery, it may change in the period leading up to surgery. In addition, if the patient is diagnosed late for proper surgery, the time available for any intervention will be limited, and there will not be enough time to make appropriate changes in the surgery list. Thus, the effectiveness of providing surgical services will be compromised [22].

The second most common reason for cancellation on surgery day was lack of time at the study hospital. Published studies from public hospitals have reported similar rates of cancellations on surgery days due to lack of time [23, 24]. Major surgeries in all specialties are performed in the study center, which sometimes requires the simultaneous attendance of several surgical specialists. These long-term surgeries disrupt the process of performing other surgeries as well.

Another common reason for cancellation on surgery’s day in this hospital was that patients did not follow guidelines, consistent with studies conducted worldwide [25, 26].

Patients turn up for their operations without following the fasting instructions or eliminating their anticoagulation medications, leading to delays, rescheduling, or cancellations. The root cause of patient noncompliance with preoperative instructions is a multifactorial and arduous problem to manage. It is possible that the surgeon did not express the specific fasting instructions and instructions for taking or removing their current medications understandably, or the patients did not remember the instructions well because of impaired memory [26]. Instructions should be given verbally, information sheets should be provided, instructions should be repeated in pre-assessment clinics, and information should be shared with all those involved in the patient’s care, such as ward staff in inpatient cases or patients relevant in day cases. Also, sending automated reminders can prepare patients for surgery and prevent cancellations. The last common reason for cancellation at the study hospital was Equipment/ supplies issues.

The limited capacity to provide basic medical equipment to diagnose and treat all referring patients can be partly attributed to the indirect effects of the Health Sector Transformation Plan (HSEP), which was carried out in hospitals affiliated with the Ministry of Health and Medical Education (MOHME), including this hospital, to reduce catastrophic health expenses (CHE) to 1% as announced in the fifth plan of economic, social and cultural development. As a result, the amount paid by patients eligible for basic health insurance will be reduced by 6% and 3% of the total hospitalization costs, and all people without basic health insurance will be covered for free [27]. In this situation, the high load of patients referring to public hospitals to use these services, the limited financial resources of the hospital, and the failure to return the hospital expenses on time by the insurance organizations reduce the ability of the hospital to provide the necessary equipment.