CHAPTER 10
PERIOPERATIVE
PATIENT SAFETY
R. Daniel Beauchamp and Michael S. Higgins
history and perspective
surgical infection prevention and surgical care
improvement project
creating an organizational structure to promote
patient safety and quality care
HISTORY AND PERSPECTIVE
Patient safety in the health care environment is recognized as
less than optimal or desirable. A series of eye-opening reports
were published in the 1990s and provided clear evidence of high
rates of serious adverse events that resulted in serious harm to
hospitalized patients. The Institute of Medicine (IOM), in its
landmark report, To Err is Human, published in 1999, estimated
that as many as 1 million people/year were injured and up to
98,000 died annually because of medical errors.1 When the
focus was specifically turned to surgical patients, surgical care
accounted for between 48% and 66% of adverse events among
nonpsychiatric hospital discharges.2 In regard to operative pro-
cedures and deliveries, 3% resulted in adverse events, and surgi-
cal adverse events were associated with a 5.6% mortality rate,
accounting for 12.2% of hospital deaths. Furthermore, 54% of
surgical adverse events were judged to be preventable.
Adverse events in surgical patients encompass those
common to all hospitalized patients, such as adverse drug events,
falls, missed diagnoses, deep venous thrombosis, pulmonary
embolism, aspiration events, respiratory failure, nosocomial
pneumonia, myocardial infarction, and cardiac arrhythmias. In
addition, surgical specific adverse events include technique-
related complications, wound infections, and postoperative
bleeding.
In 2000, the IOM called for a national effort to reduce
medical errors by 50% within 5 years; however, progress has
fallen far short of that goal, despite numerous private and public
initiatives aimed at finding solutions. Leape and colleagues3 have
proposed that these efforts fell short because health care organi-
zations did not undertake the major cultural changes required
to accomplish true and lasting improvements in performance.
They proposed that health care entities must become high-
reliability organizations that hold themselves accountable to
offer safe andeffective patient-centered care consistently. They
proposed five transforming concepts for adoption by health care
organizations seeking such cultural transformative changes:
1. Transparency must be a practiced value in everything
we do.
2. Care must be delivered by multidisciplinary teams
working in integrated care platforms.
3. Patients must become full partners in all aspects of
health care.
4. Health care workers need to find joy and meaning in
their work.
5. Medical education must be redesigned to prepare
new physicians to function in this new environment.
SURGICAL INFECTION PREVENTION AND
SURGICAL CARE IMPROVEMENT PROJECT
Because surgical site infections (SSIs) were recognized as the
second most common site of nosocomial infections and a major
cause of morbidity, readmissions, excessive costs, and death, the
Centers for Medicare and Medicaid Services (CMS) and
the Centers for Disease Control and Prevention (CDC) initiated
the National Surgical Care Improvement Project (SCIP) in
2002.4 The goal of surgical infection prevention (SIP) was to
reduce the incidence and impact of SSIs in surgical populations,
particularly in high-volume procedures. In 2003, the national
SIP project convened a meeting of the Surgical Infection Preven-
tion Guideline Writers Workgroup of experts and representatives
from several surgical specialty societies to develop evidence-
based and consensus guidelines for antimicrobial prophylaxis for
abdominal and vaginal hysterectomy, hip or knee arthroplasty,
and cardiothoracic, vascular, and colon surgery.
The SIP project focused on three primary quality perfor-
mance measures. The first SIP measure was that prophylactic
antibiotics should be given within the 60-minute interval imme-
diately preceding the surgical skin incision (within 2 hours for
vancomycin, with appropriate documentation of the reason).
The second measure was that the appropriate prophylactic anti-
biotic for the scheduled procedure should be selected based on
consensus recommendations. The third SIP measure was that
the prophylactic antibiotic should be discontinued within 24
hours of the end of the procedure.
The SIP project has transitioned into the SCIP, and includes
additional process performance measures aimed at reducing
SSIs. Three additional measures to reduce SSIs have been added
to the original SIP measures: (1) glucose control in cardiac sur-
gical patients; (2) appropriate hair removal at the surgical site
(using clippers, not razors); and (3) maintenance of normother-
mia in patients undergoing colorectal operations. In addition to
201
202 SECTION I SURGICAL BASIC PRINCIPLES

Table 10-1 SCIP Measures

SET MEASURE ID NO. MEASURE SHORT NAME
Infection
SCIP-Inf-1a Prophylactic antibiotic received within 1hr prior to surgical incision, overall rate
SCIP-Inf-1b Prophylactic antibiotic received within 1hr prior to surgical incision, CABG
SCIP-Inf-1c Prophylactic antibiotic received within 1hr prior to surgical incision, other cardiac surgery
SCIP-Inf-1d Prophylactic antibiotic received within 1hr prior to surgical incision, hip arthroplasty
SCIP-Inf-1e Prophylactic antibiotic received within 1hr prior to surgical incision, knee arthroplasty
SCIP-Inf-1f Prophylactic antibiotic received within 1hr prior to surgical incision, colon surgery
SCIP-Inf-1g Prophylactic antibiotic received within 1hr prior to surgical incision, hysterectomy
SCIP-Inf-1h Prophylactic antibiotic received within 1hr prior to surgical incision, vascular surgery
SCIP-Inf-2a Prophylactic antibiotic selection for surgical patients, overall rate
SCIP-Inf-2b Prophylactic antibiotic selection for surgical patients, CABG
SCIP-Inf-2c Prophylactic antibiotic selection for surgical patients, other cardiac surgery
SCIP-Inf-2d Prophylactic antibiotic selection for surgical patients, hip arthroplasty
SCIP-Inf-2e Prophylactic antibiotic selection for surgical patients, knee arthroplasty
SCIP-Inf-2f Prophylactic antibiotic selection for surgical patients, colon surgery
SCIP-Inf-2g Prophylactic antibiotic selection for surgical patients, hysterectomy
SCIP-Inf-2h Prophylactic antibiotic selection for surgical patients, vascular surgery
SCIP-Inf-3a Prophylactic antibiotics discontinued within 24hr after surgery end time, overall rate
SCIP-Inf-3b Prophylactic antibiotics discontinued within 48hr after surgery end time, CABG
SCIP-Inf-3c Prophylactic antibiotics discontinued within 48hr after surgery end time, other cardiac surgery
SCIP-Inf-3d Prophylactic antibiotics discontinued within 24hr after surgery end time, hip arthroplasty
SCIP-Inf-3e Prophylactic antibiotics discontinued within 24hr after surgery end time, knee arthroplasty
SCIP-Inf-3f Prophylactic antibiotics discontinued within 24hr after surgery end time, colon surgery
SCIP-Inf-3g Prophylactic antibiotics discontinued within 24hr after surgery end time, hysterectomy
SCIP-Inf-3h Prophylactic antibiotics discontinued within 24hr after surgery end time, vascular surgery
SCIP-Inf-4 Cardiac surgery patients with controlled 6 am postoperative blood glucose level
SCIP-Inf-6 Surgery patients with appropriate hair removal
SCIP-Inf-9 Urinary catheter removed on postoperative day 1 or 2, with day of surgery being day 0
SCIP-Inf-10 Surgery patients with perioperative temperature management
Cardiac
SCIP-Card-2 Surgery patients on beta blocker therapy prior to arrival who received a beta blocker during the perioperative period
VTE
SCIP-VTE-1 Surgery patients with recommended VTE prophylaxis ordered
SCIP-VTE-2 Surgery patients who received appropriate VTE prophylaxis within 24hr prior to surgery to 24hr after surgery

From Centers for Medicare and Medicaid Services, The Joint Commission: National Hospital Inpatient Quality Measures: Specifications Manual, Version 3.1, June, 2010
(http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228749003528).
VTE, Venous thromboembolism.

the six performance measures aimed at reducing SSIs, measures
aimed at preventing cardiovascular complications and venous
thromboembolism after major surgical procedures were pro-
posed (Table 10-1).5 To reduce perioperative ischemic heart
complications, patients who have been on -adrenergic blocking
medications prior to operation, should be maintained on beta
blockade in the perioperative period and during hospitalization.
The final SCIP measures are for the use of appropriate venous
thromboembolism prophylaxis in surgical patients at risk for
deep venous thrombosis and pulmonary embolism.
Use of Quality Data to Improve Outcomes of
Surgical Patients
How do we know which interventions work and which fail to
improve outcomes? Despite the intuitive appeal of quality- and
safety-motivated process improvements, it is challenging to gen-
erate accurate data in a timely manner to support the effective-
ness of the safety measures that have been undertaken. The rise
of health services research programs and rigorous population-
based research in academic medical centers and the involvement
of surgeons in these programs have led to several landmark

30-DAY POSTOPERATIVE MORTALITY RATE, 1991 TO 2008
3.5
3.16
3.0 3.16
2.5 2.75
2.57 2.55
2.38 2.28 2.33
(Percent)
2.0
1.5
1.0
0.5
0 (15 years from inception through fiscal year
1996 1998 2000
3
95
99
19
.1
g.
c
De
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1
4
99
99
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1
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Ja
studies that have helped identify some risk factors that affect
morbidity and mortality in surgical populations. The develop-
ment of broad-based prospective databases, such as the Ameri-
can College of SurgeonsNational Surgical Quality Improvement
Program (ACS-NSQIP) database, the Society of Thoracic Sur-
geons (STS) national database, and the American College of
Surgeons National Trauma Data Bank (NTDB) are all examples
of the development of critical tools necessary for such important
population-based outcomes research to be completed.
The National Veterans Affairs Surgical Quality Improve-
ment Program was initiated in 1991 to improve surgical out-
comes in Veterans Administration (VA) hospitals.6 The NSQIP
is a risk-adjusted outcomes database comprised of over 90 data
elements gathered by specially trained nurses who review the
preoperative, intraoperative, and postoperative periods. This
database was validated in the VA system, in which the data are
provided back to hospitals and providers and used to inform
strategies aimed at reducing morbidity and mortality, with con-
siderable success (Fig. 10-1).7
The ACS-NSQIP is a national civilian database launched
in 2004 as an outgrowth of the VA NSQIP. The ACS-NSQIP
is a prospectively collected, multi-institution clinical registry
database of general and vascular surgery patients that provides
feedback on risk-adjusted outcomes to member hospitals across
the United States for quality improvement purposes; however,
the data are also available for population-based research. A
recent examination of the ACS-NSQIP data reviewed the
overall and major complication rates and risk-adjusted death
rates of 84,730 patients who underwent inpatient general or
vascular surgical procedures from 2005 through 2007.8 Inter-
estingly, the death rates in these surgical patients ranged from
3.5% in the quintile of very low-mortality hospitals to 6.9% in
the quintile of very high-mortality hospitals (double the rate of
the low mortality hospitals), whereas the rates of overall and
major complications were not significantly different when com-
paring these two groups of hospitals. The difference in overall
risk-adjusted mortality was almost twice as high after a major
complication in the very high-mortality hospitals (21.4%) as
Perioperative Patient Safety Chapter 10 203
SECTION I SURGICAL BASIC PRINCIPLES
2.14 2.08
1.99
1.7 1.66
1.52
1.36
FIGURE 10-1 Actual mortality trend for the
National Surgery Quality Improvement Program
2002 2004 2006 2008 2008). (From the Congressional Budget Office:
Quality initiatives undertaken by the Veterans
Health Administration, August 2009 [http://
www.cbo.gov/ftpdocs/104xx/doc10453/08-
13-VHA.pdf].)
compared with the very low-mortality hospitals (12.5%).
Although processes and systems aimed at the avoidance of com-
plications seem intuitively important, it is not always possible
in the performance of complex procedures, particularly in pop-
ulations at high risk. This report demonstrated that failure to
rescue patients after a serious complication was associated with
an increased death rate in the high-mortality hospitals as com-
pared with the low-mortality hospitals. The same authors found
similar results when analyzing patient outcomes from a Medi-
care database.9
Effective Teams and Communication
Perioperative team building has parallels in the aviation industry
in that teams intermittently come together for relatively short,
defined periods of time to accomplish a complex task, requiring
the specialized skills of each team member, under potentially
stressful conditions in which there is inherent danger. A recent
investigation of the impact of implementing a standardized sur-
gical safety checklist (Box 10-1) has demonstrated that compli-
cation rates ranged from 6.1% to 21% (total of 11%) of 3733
surgical patients across eight major hospitals in eight cities
worldwide and the rate of postoperative death ranged from 0.8%
to 3.7% (total of 1.5%) prior to implementation of the check-
list.10 After implementation of the surgical checklist with preop-
erative sign-in, time-out and postprocedural sign-out elements
the overall rate of complications decreased to 7% (range, 3.6%
to 9.7%) and the rate of death declined to 0.8% (range, 0% to
1.7%).10
The Joint Commission (TJC) has made the implementa-
tion of the Universal Protocol for the prevention of wrong site,
wrong-patient, and wrong-procedure surgery, including the
preprocedural time-out, accreditation requirements.11,12 The
Universal Protocol includes the following elements: pre
procedural verification, site marking, and final verification
during the preprocedural time-out. The preprocedural verifica-
tion includes verification of the appropriate history and physical
examination in the medical record, presence of a signed consent
form, nursing assessment, and preanesthesia assessment (when
204 SECTION I SURGICAL BASIC PRINCIPLES
BOX 10-1 Elements of the Surgical Safety Checklist
Sign In
Before induction of anesthesia, members of the team (at least
the nurse and an anesthesia professional) state that the follow-
ing have been done:
The patient has verified his or her identity, surgical site and
procedure, and consent.
The surgical site is marked or site marking is not
applicable.
The pulse oximeter is on the patient and functioning.
All members of the team are aware of whether the patient
has a known allergy.
The patients airway and risk of aspiration have been
evaluated and appropriate equipment and assistance are
available.
If there is a risk of blood loss of at least 500mL (or 7mL/
kg body weight in children), appropriate access and fluids
are available.
Time-Out
Before skin incision, the entire team (nurses, surgeons, anes-
thesia professionals, and any others participating in the care of
the patient) states aloud the following:
Confirms that all team members have been introduced by
name and role
Confirms the patients identity, surgical site, and procedure
Reviews the anticipated critical events
Surgeon reviews critical and unexpected steps, opera-
tive duration, anticipated blood loss
Anesthesia staff review concerns specific to patient
Nursing staff reviews confirmation of sterility, equip-
ment availability, other concerns
Confirms that prophylactic antibiotics have been adminis-
tered 60min before incision is made or that antibiotics are
not indicated
Confirms that all essential imaging results for correct patient
are displayed in OR
Sign Out
Before the patient leaves the operating room, the following are
done:
Nurse reviews the following aloud with the team:
Name of procedure, as recorded
That needle, sponge, and instrument counts are com-
plete (or not applicable)
That specimen (if any) is correctly labelled, including
patients name
Whether there are any issues with equipment that
need to be addressed
The surgeon, nurse, and anesthesia professional review
aloud the key concerns for the recovery and care of the
patient.
Adapted from Haynes AB, Weiser TG, Berry WR, etal: A surgical safety checklist
to reduce morbidity and mortality in a global population. N Engl J Med 360:491
499, 2009.
applicable). It also includes verification that the necessary diag-
nostic laboratory, radiology, and other test results are present and
properly displayed. The requirement for and presence of blood
products, implants, devices, and/or special equipment is also
confirmed in the preprocedural verification process.
The time-out that occurs immediately prior to initiation of
the procedure provides a final verification of the correct patient,
correct site, and correct procedure. The time-out is most effec-
tive when it is standardized and conducted consistently across
all procedural areas of the hospital; it should be conducted
immediately before starting an invasive procedure or making the
incision. It is initiated by a designated member of the procedural
team and involves the immediate members of the procedure
team. During the time-out, other activities are suspended to as
much as possible so that team members may focus on active
confirmation of the patient, site, and procedure. Any new team
members should be introduced. At a minimum, the team
members must agree on the correct patient identity, correct
procedural site (with the site marking verified when laterality or
level is a concern), and procedure to be done. Finally, comple-
tion of the time-out should be documented for the patient
medical record.
This description of the surgical time-out defines the
minimal criteria to satisfy TJC requirements; however, if these
are the only elements included in the process, the positive impact
will be limited. The Crew Resource Management (CRM) train-
ing and discipline around the Universal Protocol enables orga-
nizations to enhance communication between health care
professionals in the perioperative management teams and to
incorporate process improvement measures, such as those
defined by the SCIP, into the checklists. These evidence-based
interventions include timely administration of perioperative
antibiotics, administration of beta blockers in patients at risk of
ischemic heart disease, venous thromboembolism prophylaxis,
and intraoperative normothermia. The time-out checklist may
also include availability and sterility of instrumentation and
implantable devices. The conclusion of the optimal surgical
time-out should include an open invitation for any member of
the team to speak up at any time during the procedure if she or
he recognizes a problem that poses risk to the patient or health
care team.
Handoffs and Surgical Safety
During the surgical experience, patients are managed by teams
of physicians and nurses that commonly transfer primary
responsibility for patient care between one another. Unfortu-
nately, transfers of care have been demonstrated to be associated
with an increase in medical errors.13,14 In a recent review of 258
surgical errors from closed malpractice claims, breakdowns in
communication were determined to be a factor in almost 25%.15
Another study examined the handover of patients in the inten-
sive care unit (ICU) and noted that significant degradation of
important patient information occurred frequently during these
transfers of care.16 Medication discrepancies have also shown to
be common in resident sign-out lists.
To address these communications challenges, experts have
turned to other high-risk industries, such as nuclear power and
the space program, to understand their strategies better and
apply useful practices to health care. There are unique differences
between the work environments in these industries and health
care, which can present challenges to the direct transfer of
approaches. However, the use of checklists and structured com-
munication procedures such as SBAR (situation-background-
assessment-recommendation) have been advocated almost
universally.17 As a result of this emerging evidence of the impor-
tance of communication in medical errors, TJC made the

standardization of hand-off communications a national patient
safety goal and an area of focus for institutional reviews. Also,
the use of simulation has been advocated to improve the effec-
tiveness of teaching hand-off procedures and for use in the
assessment of performance. As reviewed elsewhere in this chapter,
the use of information technology has been demonstrated to
improve patient hand-offs and has been leading to the imple-
mentation of new tools in large health care systems, such as the
Veterans Administration.
Phases in Perioperative Care
Preoperative Phase Preoperative preparation, review of the
clinical history, relevant radiologic images, pathology, relevant
anatomy, and anticipation of potential problems that may be
encountered during the course of the operative procedure are
essential components of the surgeons preparation. Communica-
tion with the patient and/or family members is critical to ensure
that all are in agreement regarding the operation, site of proce-
dure, risks, benefits, and possible alternative approaches. Docu-
mentation of a discussion of these should be included as part of
the consent for operation. Comorbidities and their possible
impact on outcome should be assessed and understood by the
surgeon, the anesthesiologist, and the patient and family.
Intraoperative Phase The operating room is a complex and often
high-stress environment in which there are multiple opportuni-
ties for the occurrence of errors or events that could adversely
affect patient outcomes. As noted, the Universal Protocol initi-
ated in the preoperative holding area is continued and com-
pleted in the operating room to minimize the risk of wrong
surgery. We believe that the time of anesthetic induction, patient
positioning, and performance of the time-out are critical por-
tions of any surgical procedure that requires the presence and
collaborative involvement of the attending surgeon, the anesthe-
siologist and/or anesthetist, scrub nurse, and circulating nurse
to achieve the maximum safety and quality of care. This is a
critical time for the surgeon and anesthesiologist to communi-
cate regarding the anticipated intraoperative course, anticipated
problems, including blood loss, anticipated case length, and any
special requests. Special requests may include avoidance of exces-
sive crystalloid in an older patient with a history of heart failure
or chronic obstructive pulmonary disease. It may also include
the avoidance of long-acting muscle relaxants in patients under-
going resections that are near important motor nerve structures,
such as in the face, neck, or axilla. This early phase of the
operation is also an excellent opportunity to put all in the room
at ease, introduce any new team members and, as noted earlier,
invite participants to speak up at any time during the procedure
if there are questions or concerns. To enhance the safe conduct
of the operation, a neutral zone between the surgeon and scrub
nurse should be defined and agreed on for sharp instruments.
The surgeons responsibility is to perform the operative
procedure with the utmost skill, efficiency, and safety. During
the surgical procedure, the surgeon should continually com-
municate with the anesthesiologist and the rest of the team
regarding the progress of the operation, any unexpected find-
ings, hemorrhage, or technical complications. Similarly, the
anesthesia team should communicate any significant changes in
the physiologic status of the patient, especially those related to
hypotension, O2 desaturation events, and critical laboratory
values. Such communications should be verified in both
Perioperative Patient Safety Chapter 10 205
directions by verbal acknowledgment, and a plan of management
SECTION I SURGICAL BASIC PRINCIPLES
should be agreed on. In addition, the surgeon and operating
room (OR) team must communicate regarding the instrument,
needle, and sponge counts and requirement, if any, for intraop-
erative imaging to confirm the absence of unplanned retained
foreign bodies. Confirmation of the disposition of pathologic
specimens should also occur between the surgeon and circulat-
ing nurse prior to the surgeon and patient leaving the operating
room. In addition, the checkout procedure should include dis-
cussion between the surgeon and anesthesiologist regarding
postoperative disposition of the patient. This should include
agreement about the need for special postoperative care, such as
intensive care, anticipated prolonged recovery room stay, and
need for telemetry.
Postoperative Phase For most patients, the immediate postop-
erative period consists of a monitored period of transition to
normal neurophysiologic function, with some treatment of pain,
nausea, and body temperature being relatively common.
Although relatively rare, catastrophic complications such as
myocardial ischemia or infarction, stroke, airway obstruction,
and acute hemorrhage may occur. In addition, there is occasion-
ally the need for continued pharmacologic and fluid therapy
management during the early postoperative phase. Early recog-
nition and effective intervention to correct physiologic derange-
ments associated with impending crisis are key to rescuing
patients at risk. This requires an efficient and collaborative team
of caregivers who have instituted a system of excellent commu-
nication. Effective intervention also requires multidisciplinary
collaborative teams of providersoften including specialty con-
sultative servicesappropriate escalation of care, timely imple-
mentation of antibiotic therapy for sepsis, effective critical care
teams, and appropriate interventions aimed at the source of the
complication. Ghaferi and colleagues9 have pointed out that
effective recognition and communication regarding patient
status requires a high-quality nursing staff, with staffing ratios
sufficient to enable nurses to perform regular patient assess-
ments. For example, studies have demonstrated an association
between a high nurse-to-bed ratio and decreased perioperative
mortality.18 The higher nurse-to-patient ratios are also associated
with greater job satisfaction and reduced rates of burnout among
nurses. As noted, appropriate and timely escalation of care is
crucial for patients who have become ill from a serious compli-
cation. This often involves transfer of a patient to an ICU, in
which an increased nurse-to-patient ratio is associated with
reduced resource use and daily rounds by a dedicated inten
sive care physician is associated with reduction in inpatient
mortality.19
Physician Fatigue and Surgical Safety
There has been increased focus on the relationship of physician
fatigue and patient safety that gained prominence with the
publication of To Err Is Human.1 Based in part on emerging data
regarding physician fatigue and performance, including in
the procedural environment,20 the Accreditation Council for
Graduate Medical Education (ACGME) mandated duty hour
restrictions for physician in training in 2003, with recent recom-
mendations by an IOM committee to extend those restrictions.21
Some studies have demonstrated variable results regarding
the impact of these changes on patient safety. A study of interns
working in ICUs has shown that the medical error rate is reduced
206 SECTION I SURGICAL BASIC PRINCIPLES
with work hour restrictions.22 However, another study
has shown higher error rates after the implementation of work
hour restrictions in New York.23 Larger scale studies have
demonstrated similar variability. Investigations of all Medicare
beneficiaries and VA hospitals24 have failed to demonstrate a
change in mortality for surgical patients. However, a more recent
investigation has noted a reduction in the percentage of surgical
complications attributed to providers, from 48.3% to 38.6%,
and a reduction in mortality rate, from 1.9% to1.1%, after the
restrictions, with the improvement attributed to the increased
participation of attending surgeons in clinical care and possibly
to other concurrent improvement initiatives.25
Various hypotheses have been advanced to explain the vari-
able results of duty hour restrictions. One argument is that the
initial restriction of duty hours did not limit prolonged shifts
that were thought to have the greatest impact on performance.
In addition, the resulting increase in patient hand-offs, which
are known to increase the risk of errors, may offset the improved
safety from reduced fatigue. Duty hour restrictions may not
necessarily translate into reduced fatigue. It has also been sug-
gested that shift length has a greater impact on patient safety
than overall hours.26 Hour restrictions may also interfere with
physician education, which can negatively affect clinical perfor-
mance and patient safety. These effects are certainly reinforced
by surgical resident perceptions.
Several recent surveys have shown a negative impact of
resident duty hour restrictions on attending surgeon job satisfac-
tion, time for teaching, and overall workload.27,28 An early inves-
tigation after the duty hour restrictions showed that general
surgeons worked a mean (standard deviation [SD]) of 73.8
(14.1) hours/week and only 44% reported 1 day/week away
from clinical duties.29 In a study of surgical errors, fatigue was
self-reported by attending physicians as a contributing factor in
16% of adverse events.30 Although a retrospective review of
cardiac procedures performed by sleep-deprived surgeons has
shown no difference in complication rates,31 more recent work
has shown an association between limited sleep opportunity,
increased work duration, and complication rates.32 As a result of
these emerging data, some have argued that attending surgeon
duty hours should be limited as well, and a variety of strategies
have been proposed, such as implementing a surgical hospitalist
service.
Despite the conflicting data, it seems logical that rested
physicians make better decisions that should improve patient
safety. For these reasons, work week and shift length limitations,
napping, and other validated strategies to reduce fatigue may
have beneficial effects on surgical patient safety. However, the
resulting expansion of the labor pool is estimated to cost as much
as $3.4 million/life saved, making this a substantial economic
issue for the health care system, especially for academic medical
centers.33 Moreover, the known safety risks that result from the
increased number of lesser trained providers and the increased
frequency of hand-offs must be considered. These concerns may
be addressed by strategies to improve competency through the
use of communication tools, such as checklists, and structured
communications at critical events, such as transitions in care.
There is also a significant need for additional research to under-
stand the complex association between interventions designed
to improve physician fatigue and their relationship to the safety
of surgical patients in complex health care delivery systems
better.
Use of Information Technology to Enhance
Surgical Patient Safety
The IOMs seminal report, Crossing the Quality Chasm: A New
Health System for the 21st Century, called for a radical redesign
of the health care system, with a focus on the use of information
technology as a means to improve the quality and safety of
health care and reduce cost.33a Since then, the federal govern-
ment has made significant investments to improve the develop-
ment and deployment of health care information technology
(HCIT), including the establishment of a federal executive posi-
tion of National Coordinator for Health Information Technol-
ogy and financial incentives in efforts to promote widespread
adoption of HCIT.
Computerized Order Entry
Computerized provider order entry (CPOE) is recommended
by the Agency for Healthcare Research and Quality and the
National Quality Forum as one of the 30 safe practices for better
health care. The Leapfrog group has also recommended CPOE
implementation as one of its first three recommended leaps for
improving patient safety. These positions are informed by the
evidence that 90% of medication errors occur at the ordering or
prescribing step and that clinical decision support systems
(CDSSs), which are the engines for CPOEs, have been demon-
strated to reduce drug administration errors significantly.34
Despite these strong recommendations, hospitals have been
slow to implement CPOE. A 2009 study found that only 17%
of U.S. hospitals had implemented a CPOE system, and the
proportion of outpatient practices using CPOE is even smaller.35
Cost is likely a major factor, as is the resistance to change at the
organizational and individual provider levels coupled with a lack
of systems that have been implemented successfully in a variety
of clinical settings.
CPOE and computerized prescription writing already have
shown the ability to reduce medical errors and variability in
surgical patient care. A large study in Texas has demonstrated
an improvement in mortality for patients undergoing coronary
artery bypass grafting (CABG).36 Vikoren and colleagues37 have
demonstrated the ability of a CPOE to reduce variability in
patient care for patients undergoing total joint surgery. Compli-
ance with medication and care protocols related to national
quality initiatives, such as SCIP, are improved with the use of
CPOE systems, as demonstrated for perioperative blood glucose
control,38 prophylactic antibiotic administration,39 and other
quality initiatives.
Other work, however, has shown no change in medication
errors for surgical patients after CPOE implementation.40 One
study has shown a reduction in medication errors but an overall
increase in mortality, thought to have resulted from other effects
on patient care work flow.41 These results have prompted inves-
tigations of all the factors related to CPOE implementations that
could affect patient care (Box 10-2).42-44 There are also issues
related to the underlying clinical decision support systems that
may affect outcomes. Specifically, the guidelines may not be
applicable to all clinical environments and may not be current.
Consequently, Weir and associates have recommended the
implementation of a set of safety indicators that should be
tracked during CPOE implementation to ensure that any risks
are mitigated.45 Also, clinicians must ensure that the decision
support algorithms are reviewed and validated prior to imple-
mentation to benefit from drug interaction alerts and other

BOX 10-2 Types of Unintended Consequences of
Computerized Provider Order Entry Systems
More or new work for clinicians
Unfavorable work flow issues
Never-ending system demands
Problems related to persistence of paper orders
Unfavorable changes in communication patterns and
practices
Negative feelings toward the new technology
Generation of new types of errors
Unexpected changes in an institutions power structure,
organizational culture, or professional roles
Overdependence on the technology
From Campbell EM, Sittig DF, Ash JS, etal: Types of unintended consequences
related to computerized provider order entry. J Am Med Inform Assoc 13:547556,
2006.44
critically important decision support measures.46 Similarly, a
system was developed to test CPOE systems against the criteria
established by the Leapfrog group that CPOEs should detect at
least 50% of common prescribing errors.47
Other Applications for Information Technology in
Surgical Patient Safety
There is evidence to suggest that a significant number of surgical
errors occur because of poor communication and lack of access
to critical patient information. In a root cause analysis of oper-
ative and postoperative events from 1995 to 2002, TJC found
that almost 70% of events were associated with communication
failures. Other studies have shown that transitions of care are
associated with higher risk for errors, as well as demonstrating
an increase in medical errors with an increase in the number of
patient transfers.14 Various strategies have been successfully used
to improve surgical safety, including the use of standardized
communication events and checklists. Several information tech-
nology solutions have been suggested to enhance these and other
strategies to improve surgical patient safety. The use of computer
checklists has been demonstrated as a means to transfer patient
information more effectively and efficiently. Similarly, a comput-
erized medication reconciliation process can improve continua-
tion of medications postoperatively.48 The use of information
management systems for the documentation of perioperative
care also provides the opportunity for the use of clinical decision
support algorithms and care alerts to improve antibiotic redos-
ing49 and compliance with surgical time-out elements.
Emerging technologies may also prove to be beneficial,
including the use of bar code and radiofrequency tracking
systems as a means to eliminate never events, such as wrong-
patient and wrong-site surgery and retained foreign objects.
Intraoperative video systems may also allow the opportunity to
record and debrief procedures during patient care, as they have
in emergency departments, or potentially to monitor and inter-
cede to provide enhanced patient support.
CREATING AN ORGANIZATIONAL STRUCTURE TO
PROMOTE PATIENT SAFETY AND QUALITY CARE
The health care culture must be changed to focus on quality
care and patient safety. As noted earlier, Leape and coworkers3
have proposed five transforming concepts for adoption by health
Perioperative Patient Safety Chapter 10 207
care organizations that seek such transformative changes (see
SECTION I SURGICAL BASIC PRINCIPLES
earlier).
How do we change the culture to incorporate these con-
cepts? At our institution (Vanderbilt University Medical Center,
Nashville, Tenn), the commitment has been made to change the
culture from the top of the organization. Of the five pillars of
excellence that form the framework for setting organizational
goals and direction, quality is the central pillar. The other four
pillars include people, service, growth and finance, and innova-
tion. Under the quality pillar, institutional goals are set on an
annual basis and the entire medical center is managed and oper-
ated within a framework to accomplish the goals that have been
set. Each year, the goals become more challenging to continue
to drive improvements.
Institutionally, there is a chief quality officer who works
with clinical leadership, nursing, and administration within the
patient care areas to identify priorities and identify necessary
resources to support quality improvement and address safety
issues promptly. Our Center for Clinical Improvement provides
assistance with resources to support root cause analyses of patient
deaths, adverse outcomes, and near-misses. Reporting adverse
outcomes and near-misses is encouraged in a blame-free envi-
ronment. Within the Perioperative Enterprise, there is a Surgical
Site Infection Collaborative and Perioperative Quality and
Safety Committee that collaborate with each another and that
receive input from the various surgical services, perioperative
nursing services, and infection control services. Each surgical
service conducts weekly to biweekly morbidity, mortality, and
improvement (MM&I) conferences. Cases identified in these
service-level MM&I conferences that exemplify systems con-
cerns or issues are referred to a multidisciplinary MM&I com-
mittee, which selects cases for presentation at an institution-wide
MM&I conference that is held on a quarterly basis.
Organizational transparency is achieved through the
sharing of performance data across the institution. Quality and
safety performance data are fed back to the clinicians and staff
on a monthly basis, with benchmark comparators when avail-
able. Multidisciplinary teams are central to how we are organized
around patient care, quality, and safety. The patient is central to
all we do in the clinical care setting and, within our service pillar
goals, are patient satisfaction targets dependent on provider or
physician-patient communication. Under our people pillar goals
are faculty and staff satisfaction goals, because we believe that
health care workers who are happy in their roles and feel fulfilled
provide better quality care. We reward such behaviors financially
and symbolically. We teach the students in our medical center,
at all levels, how each member of the team contributes to quality
care and safety, and this is incorporated into the medical and
nursing curriculum.
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