You could be reading the full-text of this article now if you...

If you have access to this article through your institution,
you can view this article in

Safety Culture and Complications After Bariatric Surgery

Birkmeyer, Nancy J. O. PhD*; Finks, Jonathan F. MD*; Greenberg, Caprice K. MD; McVeigh, Andrea MS*; English, Wayne J. MD; Carlin, Arthur MD§; Hawasli, Abdelkader MD; Share, David MD, MPH; Birkmeyer, John D. MD*

Annals of Surgery:
doi: 10.1097/SLA.0b013e31826c0085
Original Articles

Objective: To assess relationships between safety culture and complications within 30 days of bariatric surgery.

Background: Safety culture refers to the quality of teamwork, coordination, and communication, as well as responses to error in health care settings. Although safety culture is thought to be an important determinant of surgical outcomes, few studies have examined this empirically.

Methods: We surveyed staff from 22 Michigan hospitals participating in a statewide bariatric surgery collaborative. Each safety culture survey item was rated on a 1 to 5 Likert scale with lower scores representing better patient safety culture. These data were linked to clinical registry data for 24,117 bariatric surgery patients between 2007 and 2010. We used negative binomial regression to calculate incidence rates and incidence rate ratios measuring the increase in hospitals' rate of complications per unit increase in safety culture (individual items as well as hospital and operating room-specific subscales), controlling for patient risk factors, procedure mix, and bariatric procedure volume.

Results: All 22 hospitals participated in this study, submitting safety culture ratings from 53 surgeons, 102 nurses, and 29 operating room administrators. Rates of serious complications were significantly lower among hospitals receiving an overall safety rating of excellent from nurses (1.5%), compared with those receiving a very good (2.6%) or acceptable (4.6%) rating (P = <0.0001). Surgeons' overall safety ratings were also associated with rates of serious complications (2.1% excellent, 2.6% very good, 4.7% acceptable, P = 0.011). Nurses' ratings of the hospital-specific subscale (P = 0.002) and surgeons' ratings of the operating room-specific subscale (P = 0.045) were also associated with rates of serious complications. Of the individual items, those related to coordination and communication between hospital units were the most strongly associated with rates of complications. Operating room administrator ratings of safety culture were not related to rates of complications for any of the domains of safety culture studied.

Conclusions: Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.

In Brief

Data from 22 Michigan hospitals demonstrate that safety culture is associated with rates of surgical complications in bariatric surgery. Interventions targeting safety culture, particularly coordination and communication, seem to be most important for quality improvement.

Author Information

*Department of Surgery and Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI

Department of Surgery and Wisconsin Surgical Outcomes Research Program, University of Wisconsin, WI

Department of Surgery, Marquette General Hospital, Marquette, MI

§Department of Surgery, Henry Ford Hospital, Detroit, MI

Department of Surgery, St John Hospital and Medical Center, Detroit, MI

Department of Family Medicine, University of Michigan, Ann Arbor, MI.

Reprints: Nancy J.O. Birkmeyer, PhD, Center for Healthcare Outcomes and Policy, Bldg 16, North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109. E-mail:

Disclosure: This work was funded by an unrestricted, longitudinal research contract from Blue Cross and Blue Shield of Michigan and Blue Care Network.

© 2013 Lippincott Williams & Wilkins, Inc.