Effect of a Comprehensive Surgical Safety System on Patient Outcomes — NEJM

Effect of a Comprehensive Surgical Safety System on Patient Outcomes

Eefje N. de Vries, M.D., Ph.D., Hubert A. Prins, M.D., Ph.D., Rogier M.P.H. Crolla, M.D., Adriaan J. den Outer, M.D., George van Andel, M.D., Ph.D., Sven H. van Helden, M.D., Ph.D., Wolfgang S. Schlack, M.D., Ph.D., M. Agnès van Putten, B.Sc., Dirk J. Gouma, M.D., Ph.D., Marcel G.W. Dijkgraaf, Ph.D., Susanne M. Smorenburg, M.D., Ph.D., and Marja A. Boermeester, M.D., Ph.D. for the SURPASS Collaborative Group

N Engl J Med 2010; 363:1928-1937
November 11, 2010


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.)


Source Information

From the Departments of Surgery (E.N.V., D.J.G., M.A.B.), Quality and Process Innovation (E.N.V., M.A.P., S.M.S.), Anesthesiology (W.S.S.), and Clinical Epidemiology and Biostatistics (M.G.W.D.), Academic Medical Center; and the Department of Urology, Onze Lieve Vrouwe Gasthuis (G.A.) — both in Amsterdam; and the Department of Surgery, Jeroen Bosch Hospital, Den Bosch (H.A.P.); the Department of Surgery, Amphia Hospital, Breda (R.M.P.H.C.); the Department of Surgery, Rijnland Hospital, Leiderdorp (A.J.O.); and the Department of Surgery, Maastricht University Medical Center, Maastricht (S.H.H.) — all in the Netherlands.

Address reprint requests to Dr. Boermeester at the Department of Surgery, Academic Medical Center, Meibergdreef 9, G4-132.1 1105 AZ Amsterdam, the Netherlands, or at m.a.boermeester@amc.uva.nl.

Members of the Surgical Patient Safety System (SURPASS) Collaborative Group are listed in the Supplementary Appendix, available at NEJM.org.

Dr. Adriaan J. den Outer is deceased.
Effect of a Comprehensive Surgical Safety System on Patient Outcomes — NEJM