Background <p>Transfers within operating rooms present significant risks to patient safety, with falls potentially leading to serious consequences for both patients and staff. The aim of this study is to explore the factors contributing to falls during transfers and strategies to enhance patient safety in operating rooms.</p> Methods <p>This is a qualitative study conducted using semi-structured interviews with fifteen operating room staff including nurse (<i>n</i> = 7), anaesthesia technician (<i>n</i> = 7) and scrub person (<i>n</i> = 1). Their ages ranged from 28 to 39 years, with experience years in the operating room ranging from two to ten years. The data were analysed using a thematic analysis approach based on the grounded theory.</p> Results <p>The thematic analysis identified six key factors contributing to falls during patient transfers: human error, team coordination, patient condition, staffing challenges, equipment issues, and inadequate training. Participants recommended improving team collaboration, pre-operative patient education, better infrastructure (e.g., private elevators), hands-on training, and increased staffing. Additionally, policy changes to limit complex outpatient transfers were suggested to reduce risks.</p> Conclusions <p>This study provides valuable insights into the risk factors and potential prevention strategies regarding falls during patient transfers in operating rooms. Future research should incorporate multidisciplinary observational studies involving human factors to provide deeper insights. It is recommended to create systems for anonymous incident reporting and implement comprehensive training programs.</p>