title: Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery.
abstract: OBJECTIVE
  To perform a systematic review of interventions used to reduce adverse events in surgery.
  
  
  BACKGROUND
  Many interventions, which aim to improve patient safety in surgery, have been introduced to hospitals. Little is known about which methods provide a measurable decrease in morbidity and mortality.
  
  
  METHODS
  MEDLINE, EMBASE, and Cochrane databases were searched from inception to Week 19, 2012, for systematic reviews, randomized controlled trials (RCTs), and cross-sectional and cohort studies, which reported an intervention aimed toward reducing the incidence of adverse events in surgical patients. The quality of observational studies was measured using the Newcastle-Ottawa Scale. RCTs were assessed using the Cochrane Collaboration's tool for assessing risk of bias.
  
  
  RESULTS
  Ninety-one studies met inclusion criteria, 26 relating to structural interventions, 66 described modifying process factors. Only 17 (of 42 medium to high quality studies) reported an intervention that produced a significant decrease in morbidity and mortality. Structural interventions were: improving nurse to patient ratios (P = 0.008) and Intensive Care Unit (ITU) physician involvement in postoperative care (P < 0.05). Subspecialization in surgery reduced technical complications (P < 0.01). Effective process interventions were submission of outcome data to national audit (P < 0.05), use of safety checklists (P < 0.05), and adherence to a care pathway (P < 0.05). Certain safety technology significantly reduced harm (P = 0.02), and team training had a positive effect on patient outcome (P = 0.001).
  
  
  CONCLUSIONS
  Only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement. It is important that future research remains focused on demonstrating a measurable reduction in adverse events from patient safety initiatives.
authors.affiliation: *Department of Surgery and Cancer †Institute of Global Health Innovation, Imperial College, St Mary's Hospital, Praed Street, London, UK.
authors.forename: Ann-Marie
authors.initials: AM
authors.lastname: Howell
authors.forename: Sukhmeet S
authors.initials: SS
authors.lastname: Panesar
authors.forename: Elaine M
authors.initials: EM
authors.lastname: Burns
authors.forename: Liam J
authors.initials: LJ
authors.lastname: Donaldson
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
mesh_terms: D019985:Benchmarking; D057189:Checklist; D019091:Critical Pathways; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D010043:Outcome and Process Assessment, Health Care; D061214:Patient Safety; D010561:Personnel Staffing and Scheduling; D011785:Quality Assurance, Health Care / Q000379:methods*; D013038:Specialization; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000592:standards