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 Harder

Study

Implementing a standardized safe surgery program reduces serious reportable events.

February 4, 2015

Loftus T, Dahl D, OHare B, et al. J Am Coll Surg. 2015;220(1):12-17.e3.

View more articles from the same authors.

Implementation of a safe surgery program resulted in a sustained decrease in serious reportable events within a health system over a 2-year period. The authors ascribe the success of the program to a planning process that involved human factors engineering approaches as well as an ongoing implementation and reinforcement program.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Using radiofrequency technology to prevent retained sponges and improve patient outcomes.

October 28, 2020

Do safety briefings improve patient safety in the acute hospital setting? A systematic review.

June 5, 2019

The impact of health care strikes on patient mortality: a systematic review and meta-analysis of observational studies.

November 30, 2022

Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population.

May 19, 2021

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.

May 31, 2023

When systems fail.

March 27, 2005

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.

July 13, 2005

Improving the discharge process by embedding a discharge facilitator in a resident team.

November 16, 2011

Citing harms, momentum grows to remove race from clinical algorithms.

January 31, 2024

Interruptions and blood transfusion checks: lessons from the simulated operating room.

February 4, 2009

Errors and nonadherence in pediatric oral chemotherapy use.

September 21, 2016

Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management.

April 22, 2020

IT vulnerabilities highlighted by errors, malfunctions at veterans' medical centers.

March 18, 2009

IOM: shorten residents' work shifts to reduce fatigue, improve patient safety.

January 28, 2009

Disclosing errors that affect multiple patients.

June 3, 2009

US clinicians' experiences and perspectives on resource limitation and patient care during the COVID-19 pandemic.

January 13, 2021

Mitigating hazards through continuing design: the birth and evolution of a pediatric intensive care unit.

May 3, 2006

Consensus bundle on prevention of surgical site infections after major gynecologic surgery.

December 21, 2016

The pros and cons of electronic prescribing for children.

July 27, 2011

Opioid prescribing patterns and complications in the dermatology Medicare population.

March 7, 2018

Implementing a safe and reliable process for medication administration.

June 6, 2012

What is the NHS Safety Thermometer?

November 28, 2012

Creating a culture of safety in the emergency department: the value of teamwork training.

June 12, 2013

The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.

January 3, 2007

Use of simulation to measure the effects of just-in-time information to prevent nursing medication errors: a randomized controlled study.

January 27, 2021

Long-term sustainability and adaptation of I-PASS handovers.

September 13, 2023

Integrating simulation in surgery as a teaching tool and credentialing standard.

December 5, 2007

The Medication Manager: results of a medication at the bedside pilot in a pediatric teaching institution.

June 23, 2010

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

September 23, 2015

E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes.

March 22, 2017

Understanding factors that impact on health care professionals' risk perceptions and responses toward Clostridium difficile and methicillin-resistant Staphylococcus aureus: a structured literature review.

April 10, 2013

Preventing health care–associated harm in children.

May 14, 2014

Prospective daily review of discharge medications by pharmacists: effects on measures of safety and efficiency.

January 16, 2019

The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus Development Conference.

September 5, 2018

COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.

August 19, 2020

Findings of a naloxone database and its utilization to improve safety and education in a tertiary care medical center.

February 1, 2017

Artificial intelligence and surgical decision-making.

March 11, 2020

Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents.

April 22, 2015

Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes.

May 20, 2015

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses.

August 26, 2015

Implementing human factors in clinical practice.

April 9, 2014

When there's no one to whom an error can be disclosed, how should an error be handled?

August 14, 2019

Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles.

March 24, 2021

Nurse well-being: a concept analysis.

August 17, 2022

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial.

February 9, 2022

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study.

November 2, 2016

Complexity and challenges of the clinical diagnosis and management of Long COVID.

November 30, 2022

Associations between national board exam performance and residency program emphasis on patient safety and interprofessional teamwork.

September 11, 2019

Does employee safety matter for patients too? Employee safety climate and patient safety culture in health care.

May 20, 2015

Teaching and medical errors: primary care preceptors' views.

October 12, 2005

Chemotherapy errors: a call for a standardized approach to measurement and reporting.

June 1, 2016

Paid malpractice claims for adverse events in inpatient and outpatient settings.

January 30, 2005

Are autopsy findings still relevant to the management of critically ill patients in the modern era?

February 5, 2014

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals.

October 28, 2009

Quantification of surgical resident stress "on call".

November 30, 2005

Addressing the taboo of medical error through IGBOs: I got burnt once!

June 4, 2014

Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.

May 9, 2018

Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review.

October 17, 2018

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge.

January 8, 2020

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.

December 10, 2014

Journey to no preventable risk: The Baylor Health Care System patient safety experience.

November 3, 2010

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

August 6, 2008

Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?

September 18, 2019

Team relations and role perceptions during anesthesia crisis management in magnetic-resonance imaging settings: a mixed-methods exploration.

March 20, 2024

The justification for strike action in healthcare: a systematic critical interpretive synthesis.

April 27, 2022

Seasoned surgeons assessed in a laparoscopic surgical crisis.

May 13, 2009

Understanding the root cause analysis process to increase safety event reporting.

July 5, 2023

Building cultures of high reliability: lessons from the high reliability organization paradigm.

November 1, 2023

Knowledge is power: averting safety-compromising events in the OR.

December 17, 2008

Developing a culture of safety in ambulatory care settings.

May 30, 2007

JCAHO's National Patient Safety Goals 2006.

February 15, 2006

Factors influencing preceptors' responses to medical errors: a factorial survey.

October 19, 2005

Assessment of patient medication adherence, medical record accuracy, and medication blood concentrations for prescription and over-the-counter medications.

November 28, 2018

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.

August 3, 2016

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

May 23, 2018

Prevalence, types, and sources of bullying reported by US general surgery residents in 2019.

June 17, 2020

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States.

June 21, 2023

Unanticipated death after discharge home from the emergency department.

July 4, 2007

Application of electronic health records to The Joint Commission's 2011 National Patient Safety Goals.

July 13, 2011

Alcoholism and American healthcare: the case for a patient safety approach.

August 17, 2022

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions.

October 11, 2023

Normal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate.

January 25, 2006

Perinatal patient safety and quality.

July 6, 2011

Emerging trends in perinatal quality and risk with recommendations for patient safety.

February 14, 2018

Sources and types of discrepancies between electronic medical records and actual outpatient medication use.

September 24, 2008

Measuring perinatal patient safety: review of current methods.

May 31, 2006

Interventions to improve hand hygiene compliance in the ICU: a systematic review.

November 29, 2017

How patients perceive a doctor's caring attitude.

September 24, 2008

Nursing strategies to increase medication safety in inpatient settings.

May 25, 2016

Adverse event reporting: harnessing residents to improve patient safety.

November 8, 2017

Potential uses of AI for perioperative nursing handoffs: a qualitative study.

April 12, 2023

Supporting the emotional well-being of health care workers during the COVID-19 pandemic.

August 5, 2020

Measuring the cost of hospital adverse patient safety events.

November 10, 2010

Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary.

April 25, 2007

Complying with the 2008 national patient safety goals.

March 26, 2008

Reducing serious safety events and priority hospital-acquired conditions in a pediatric hospital with the implementation of a patient safety program.

June 6, 2018

Technology-enhanced simulation for health professions education: a systematic review and meta-analysis.

September 14, 2011

Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens.

November 26, 2014

Association of surgical resident wellness with medical errors and patient outcomes.

May 6, 2020

Intentional rounding—an integrative literature review.

August 7, 2019

Related Resources

Handbook of Perioperative and Procedural Patient Safety.

February 7, 2024

Transforming team performance through reimplementation of the surgical safety checklist.

December 6, 2023

Sentinel Event Alert 68: updated surgical fire prevention for the 21st Century.

November 8, 2023

Understanding the root cause analysis process to increase safety event reporting.

July 5, 2023

The additional cost of perioperative medication errors

July 5, 2023

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period.

June 14, 2023

The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap.

May 31, 2023

Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment.

April 26, 2023

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

April 19, 2023

WebM&M Cases

Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.

March 29, 2023

WebM&M Cases

Medication Handling and Compounding Errors in the Operating Room.

March 15, 2023

Human factors in anaesthesia: a narrative review.

February 15, 2023

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Crisis recovery in surgery: error management and problem solving in safety-critical situations.

September 14, 2022

Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study.

September 7, 2022

Performance variability in perioperative sentinel events: report on a nationwide data set.

April 20, 2022

Association between operative autonomy of surgical residents and patient outcomes.

March 23, 2022

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

March 9, 2022

"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.

January 19, 2022

Technology, Education and Safety.

December 15, 2021

Influence of perioperative handoffs on complications and outcomes.

November 17, 2021

Patient Safety Innovations

Awareness of human factors in the operating theatres during the COVID-19 pandemic

October 27, 2021

Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation.

June 9, 2021

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward.

April 14, 2021

Adaptive design: adaptation and adoption of patient safety practices in daily routines, a multi-site study.

August 12, 2020

Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice.

June 19, 2019

What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.

June 12, 2019

Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative.

May 15, 2019

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

See More About The Topic

Operating Room

Health Care Executives and Administrators

Surgery

Surgical Complications

Epidemiology of Errors and Adverse Events

Implementing a standardized safe surgery program reduces serious reportable events.

Awareness of human factors in the operating theatres during the COVID-19 pandemic

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Implementing a standardized safe surgery program reduces serious reportable events.

Awareness of human factors in the operating theatres during the COVID-19 pandemic

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site