Effect of a comprehensive surgical safety system on patient outcomes.
BACKGROUND
Adverse events in patients who have undergone surgery constitute a large proportion of iatrogenic illnesses. Most surgical safety interventions have focused on the operating room. Since more than half of all surgical errors occur outside the operating room, it is likely that a more substantial improvement in outcomes can be achieved by targeting the entire surgical pathway.


METHODS
We examined the effects on patient outcomes of a comprehensive, multidisciplinary surgical safety checklist, including items such as medication, marking of the operative side, and use of postoperative instructions. The checklist was implemented in six hospitals with high standards of care. All complications occurring during admission were documented prospectively. We compared the rate of complications during a baseline period of 3 months with the rate during a 3-month period after implementation of the checklist, while accounting for potential confounders. Similar data were collected from a control group of five hospitals.


RESULTS
In a comparison of 3760 patients observed before implementation of the checklist with 3820 patients observed after implementation, the total number of complications per 100 patients decreased from 27.3 (95% confidence interval [CI], 25.9 to 28.7) to 16.7 (95% CI, 15.6 to 17.9), for an absolute risk reduction of 10.6 (95% CI, 8.7 to 12.4). The proportion of patients with one or more complications decreased from 15.4% to 10.6% (P<0.001). In-hospital mortality decreased from 1.5% (95% CI, 1.2 to 2.0) to 0.8% (95% CI, 0.6 to 1.1), for an absolute risk reduction of 0.7 percentage points (95% CI, 0.2 to 1.2). Outcomes did not change in the control hospitals.


CONCLUSIONS
Implementation of this comprehensive checklist was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care. (Netherlands Trial Register number, NTR1943.).
Departments of Surgery, Academic Medical Center, Amsterdam, the Netherlands.
Eefje N
EN
de Vries
Hubert A
HA
Prins
Rogier M P H
RM
Crolla
Adriaan J
AJ
den Outer
George
G
van Andel
Sven H
SH
van Helden
Wolfgang S
WS
Schlack
M Agnès
MA
van Putten
Dirk J
DJ
Gouma
Marcel G W
MG
Dijkgraaf
Susanne M
SM
Smorenburg
Marja A
MA
Boermeester
D057189:Checklist; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality / Q000517:prevention & control*; D013514:Surgical Procedures, Operative / Q000592:standards*; D016896:Treatment Outcome