A systems approach to surgical safety

The documented and “accepted” incident rates in surgery are unacceptably high and there is no process in place for systematically learning from surgical incident data so that appropriate changes can be incorporated in practice.

Abstract

The documented and "accepted" incident rates in surgery are unacceptably high. Incident rates of 1–5% are generally accepted as a normal part of practice. Current morbidity and mortality reporting, while important, does not sufficiently examine or expose the active and latent errors that lead to adverse outcomes. Further. there is no process in place for systematically learning from surgical incident data so that appropriate changes can be incorporated in practice. Other high-risk industries have shown that process improvements, as well as the promotion of a culture of safety, can have a significant impact on an industry's safety record. The establishment of surgical protocols and checklists has the potential to improve the standards of training and practice, as well as enhancing operating room communications. Data collection and analysis can identify latent errors that could be addressed through better training, device design, or surgical methods. Computerbased training could be instituted to allow surgeons to practice the perceptual, decision-making, and problemsolving skills that are a major part of surgery. These kinds of activities have been incorporated successfully into other industries and should also be applied to the practice of surgery.