Implementing a standardized safe surgery program reduces serious reportable events

Terrence Loftus, Deb Dahl, Bridget Ohare, Karlene Power, Yvette Toledo-Katsenes, Ryan Hutchison, David Jacofsky, Kathleen A Harder

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


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.

Study Design 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.

Original languageEnglish (US)
Pages (from-to)12-17.e3
JournalJournal of the American College of Surgeons
Issue number1
StatePublished - Jan 1 2015

Bibliographical note

Funding Information:
Support: Funding and support for this project were provided by the Care Management Division of Banner Health and a grant from Cardinal Health Foundation .


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