Surgical adverse events: a systematic review.

Oliver Anderson; Rachel Davis; George B. Hanna; Charles A. Vincent

Review

Surgical adverse events: a systematic review.

June 26, 2013

Anderson O, Davis R, Hanna GB, et al. Am J Surg. 2013;206(2):253-62.

View more articles from the same authors.

This systematic review estimates that approximately 1 in 20 surgical patients experiences a preventable adverse event, most of which are related to periprocedural care and not errors of surgical technique.

PubMed citation

Available at

Related Resources From the Same Author(s)

A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.

May 2, 2012

Patient involvement in patient safety: the health-care professional's perspective.

November 7, 2012

Information needs in operating room teams: what is right, what is wrong, and what is needed?

January 12, 2011

Hospital patients' reports of medical errors and undesirable events in their health care.

June 27, 2012

A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patient safety video.

April 17, 2013

An examination of opportunities for the active patient in improving patient safety.

February 22, 2012

Patient involvement in patient safety: what factors influence patient participation and engagement?

August 22, 2007

Communication patterns in a UK emergency department.

October 10, 2007

Patients' and health care professionals' attitudes towards the PINK patient safety video.

June 29, 2011

Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies.

February 1, 2012

The medical student as a patient: attitudes towards involvement in the quality and safety of health care.

October 30, 2013

Reliability of a revised NOTECHS scale for use in surgical teams.

July 16, 2008

How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions.

July 10, 2013

Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study.

December 17, 2014

Science and patient safety.

October 17, 2012

Understanding and responding to adverse events.

March 6, 2005

Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care.

July 25, 2012

A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project."

August 20, 2014

Analysis of errors enacted by surgical trainees during skills training courses.

July 27, 2005

Managing risk in hazardous conditions: improvisation is not enough.

July 24, 2019

Learning from failure: the need for independent safety investigation in healthcare.

November 19, 2014

Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study.

April 1, 2015

Learning from litigation. The role of claims analysis in patient safety.

December 13, 2006

Multidisciplinary centres for safety and quality improvement: learning from climate change science.

April 27, 2011

The role of chief executive officers in a quality improvement: a qualitative study.

February 20, 2013

Managing the after effects of serious patient safety incidents in the NHS: an online survey study.

October 31, 2012

Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety.

May 21, 2014

Embracing multiple aims in healthcare improvement and innovation.

March 23, 2022

Distracting communications in the operating theatre.

June 6, 2007

A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.

May 20, 2015

Practical challenges of introducing WHO surgical checklist: UK pilot experience.

January 27, 2010

The effects of stress and coping on surgical performance during simulations.

January 13, 2010

The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients.

March 24, 2021

Prevalence and factors associated with patient-requested corrections to the medical record through use of a patient portal: findings from a national survey.

March 9, 2022

Making health care safer: what is the contribution of health psychology?

November 11, 2015

Practising safely in the foundation years.

April 22, 2009

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

Safety skills for clinicians: an essential component of patient safety.

August 20, 2008

The problem of engaging hospital doctors in promoting safety and quality in clinical care.

March 21, 2007

Taking ergonomics to the bedside—a multi-disciplinary approach to designing safer healthcare.

November 27, 2013

Engineering the system of communication for safer surgery.

February 23, 2011

Rethinking medical ward quality.

November 9, 2016

Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice.

April 11, 2018

Safety analysis over time: seven major changes to adverse event investigation.

January 24, 2018

'The ABC of Handover': impact on shift handover in the emergency department.

February 8, 2012

Development and validation of a tool to assess emergency physicians' nontechnical skills.

April 18, 2012

Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature.

April 18, 2012

Patient safety in community dementia services: what can we learn from the experiences of caregivers and healthcare professionals?

February 15, 2017

The role of hospital managers in quality and patient safety: a systematic review.

September 17, 2014

Observational assessment of surgical teamwork: a feasibility study.

October 4, 2006

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.

June 12, 2019

A vignette study to examine health care professionals' attitudes towards patient involvement in error prevention.

July 18, 2012

Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT.

May 20, 2009

Patient involvement in patient safety: how willing are patients to participate?

March 2, 2011

How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study.

April 16, 2008

Advances in perioperative quality and safety.

June 13, 2018

Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries.

March 27, 2013

Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool.

June 29, 2011

Carers' medication administration errors in the domiciliary setting: a systematic review.

February 8, 2017

Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping review.

October 25, 2023

Analysis of paediatric long-term ventilation incidents in the community

January 22, 2020

A systematic quantitative assessment of risks associated with poor communication in surgical care.

June 30, 2010

The natural lifespan of a safety policy: violations and system migration in anaesthesia.

April 28, 2010

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

August 11, 2010

Predictors of the perceived impact of a patient safety collaborative: an exploratory study.

March 23, 2011

Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews.

November 16, 2016

Healthy life-years lost and excess bed-days due to 6 patient safety incidents: empirical evidence from English hospitals.

November 2, 2016

What is known about adverse events in older medical hospital inpatients? A systematic review of the literature.

September 4, 2013

Teams under pressure in the emergency department: an interview study.

January 25, 2012

Strategies for sustaining a quality improvement collaborative and its patient safety gains.

July 11, 2012

Factors predicting change in hospital safety climate and capability in a multi-site patient safety collaborative: a longitudinal survey study.

June 20, 2012

Case-based learning for patient safety: the Lessons Learnt program for UK junior doctors.

March 29, 2012

Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.

April 9, 2014

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients.

June 18, 2014

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.

January 23, 2019

What attributes of patients affect their involvement in safety? A key opinion leaders' perspective.

September 18, 2013

Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports.

January 7, 2009

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review.

July 15, 2015

Diagnostic error in a national incident reporting system in the UK.

September 8, 2010

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

October 24, 2012

How reliable are clinical systems in the UK NHS? A study of seven NHS organisations.

April 25, 2012

Breaking the rules: understanding non-compliance with policies and guidelines.

September 28, 2011

Action on patient safety can reduce health inequalities.

April 13, 2022

Early diagnosis of cancer: systems approach to support clinicians in primary care.

April 5, 2023

Teamwork in the operating theatre: cohesion or confusion?

March 29, 2006

Incident reporting in one UK accident and emergency department.

December 21, 2005

Systems approaches to surgical quality and safety: from concept to measurement.

March 6, 2005

A perinatal care quality and safety initiative: are there financial rewards for improved quality?

July 31, 2013

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

February 26, 2014

The disparity of frontline clinical staff and managers' perceptions of a quality and patient safety initiative.

September 15, 2010

Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.

April 7, 2010

Medical engagement in organisation-wide safety and quality-improvement programmes: experience in the UK Safer Patients Initiative.

July 21, 2010

Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative.

July 8, 2009

The impact of nontechnical skills on technical performance in surgery: a systematic review.

January 30, 2005

Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors.

May 29, 2013

Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.

August 1, 2012

Observational teamwork assessment for surgery: feasibility of clinical and nonclinical assessor calibration with short-term training.

May 30, 2012

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.

November 12, 2014

Related Resources

Ambulatory Surgery Center Survey on Patient Safety Culture.

May 29, 2023

Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.

April 10, 2023

Defining and studying errors in surgical care: a systematic review.

August 17, 2022

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

WebM&M Cases

“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event

January 29, 2020

Patient safety incidents caused by poor quality surgical instruments.

September 4, 2019

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

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

June 12, 2019

Impact of the World Health Organization surgical safety checklist on patient safety.

June 12, 2019

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

May 8, 2019

Learning From Invited Reviews.

April 10, 2019

Does overlapping surgery result in worse surgical outcomes? A systematic review and meta-analysis.

February 20, 2019

Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators.

May 2, 2018

Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry.

March 7, 2018

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016.

June 21, 2017

Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study.

March 1, 2017

Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care.

December 21, 2016

Leading article: how can I optimise my role as a leader within the surgical team?

August 31, 2016

The impact of surgical safety checklists on theatre departments: a critical review of the literature.

June 22, 2016

Use of personal electronic devices by nurse anesthetists and the effects on patient safety.

May 25, 2016

The Safer Delivery of Surgical Services Program (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems.

February 24, 2016

A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital.

February 10, 2016

A 'paperless' wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement.

January 27, 2016

Patient safety in dermatologic surgery: parts 1 and 2.

September 30, 2015

An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains.

September 23, 2015

Outcomes of daytime procedures performed by attending surgeons after night work.

September 2, 2015

Preventability of hospital-acquired venous thromboembolism.

August 19, 2015

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

August 5, 2015

The Global Comparators project: international comparison of 30-day in-hospital mortality by day of the week.

July 29, 2015

National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.

July 8, 2015

See More About The Topic

Operating Room

Physicians

Nurses

Health Care Executives and Administrators

Surgery

Surgical adverse events: a systematic review.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Surgical adverse events: a systematic review.

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