title: Implementing a standardized safe surgery program reduces serious reportable events.
abstract: BACKGROUND
  Patient safety in the perioperative period is essential for delivery of quality patient care. Mainstream quality organizations have implemented safe surgery recommended practices for ensuring patient safety. Effectively implementing safe surgery practices should result in a reduction in serious reportable event (SRE) rates.
  
  
  METHODS
  This retrospective cohort study compared results before and after implementation of a standardized safe surgery program across a large health care system. Observational audits were performed to assure adoption of the new process. Serious reportable event rates (retained surgical item, wrong site, wrong patient, and wrong procedure) were tracked. Statistical analyses were performed on the SRE rate and days between SREs.
  
  
  RESULTS
  A total of 683,193 cases in the operating room and labor and delivery were evaluated over a 4-year period. The SRE rate before implementation was 0.075/1,000 cases and after implementation was 0.037/1,000 cases. There was a 52% reduction in the SRE rate (p < 0.05). The mean time between SREs increased from 27.4 days to 60.6 days (p < 0.05). Robotic and nonrobotic cases were affected equally; however, a significant difference in SRE rate persisted between robotic and non-robotic cases (p < 0.05). Robotic cases are 7 times more likely to incur an SRE. Audits demonstrated that the compliance rates for the program improved to 96% after complete system implementation.
  
  
  CONCLUSIONS
  An effectively implemented standardized safe surgery program results in a significant reduction in SREs. Robotic cases are at high risk for an SRE.
authors.affiliation: Division of Care Management, Banner Health, Phoenix, AZ. Electronic address: tloftus@cox.net.
authors.forename: Terrence
authors.initials: T
authors.lastname: Loftus
authors.affiliation: Division of Care Management, Banner Health, Phoenix, AZ.
authors.forename: Deb
authors.initials: D
authors.lastname: Dahl
authors.affiliation: Division of Care Management, Banner Health, Phoenix, AZ.
authors.forename: Bridget
authors.initials: B
authors.lastname: OHare
authors.affiliation: Perioperative Services, Banner Health, Phoenix, AZ.
authors.forename: Karlene
authors.initials: K
authors.lastname: Power
authors.affiliation: Division of Care Management, Banner Health, Phoenix, AZ.
authors.forename: Yvette
authors.initials: Y
authors.lastname: Toledo-Katsenes
authors.affiliation: Division of Care Management, Banner Health, Phoenix, AZ.
authors.forename: Ryan
authors.initials: R
authors.lastname: Hutchison
authors.affiliation: The CORE Institute, Phoenix, AZ.
authors.forename: David
authors.initials: D
authors.lastname: Jacofsky
authors.affiliation: Center for Design in Health, University of Minnesota, Minneapolis, MN.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Harder
mesh_terms: D015331:Cohort Studies; D006801:Humans; D008485:Medical Audit; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care; D061214:Patient Safety / Q000592:standards*; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000458:organization & administration; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000592:standards*