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Perception of Safety of Surgical Practice Among Operating Room Personnel From Survey Data Is Associated With All-cause 30-day Postoperative Death Rate in South Carolina

Molina, George MD, MPH*,†; Berry, William R. MD, MPA, MPH*; Lipsitz, Stuart R. ScD*; Edmondson, Lizabeth BA*; Li, Zhonghe MS*; Neville, Bridget A. MPH*; Moonan, Aunyika T. PhD, CPHQ; Gibbons, Lorri R. MSHL, RN, CPHQ; Gawande, Atul A. MD, MPH*; Singer, Sara J. PhD, MBA*,§,¶; Haynes, Alex B. MD, MPH*,†

doi: 10.1097/SLA.0000000000002378

Objective: To evaluate whether the perception of safety of surgical practice among operating room (OR) personnel is associated with hospital-level 30-day postoperative death.

Background: The relationship between improvements in the safety of surgical practice and benefits to postoperative outcomes has not been demonstrated empirically.

Methods: As part of the Safe Surgery 2015: South Carolina initiative, a baseline survey measuring the perception of safety of surgical practice among OR personnel was completed. We evaluated the relationship between hospital-level mean item survey scores and rates of all-cause 30-day postoperative death using binomial regression. Models were controlled for multiple patient, hospital, and procedure covariates using supervised principal components regression.

Results: The overall survey response rate was 38.1% (1793/4707) among 31 hospitals. For every 1 point increase in the hospital-level mean score for respect [adjusted relative risk (aRR) 0.78, 95% CI 0.65–0.93, P = 0.0059], clinical leadership (aRR 0.86, 95% CI 0.74–0.9932, P = 0.0401), and assertiveness (aRR 0.71, 95% CI 0.54–0.93, P = 0.01) among all survey respondents, there were associated decreases in the hospital-level 30-day postoperative death rate after inpatient surgery ranging from 14% to 29%. Higher hospital-level mean scores for the statement, “I would feel safe being treated here as a patient,” were associated with significantly lower hospital-level 30-day postoperative death rates (aRR 0.83, 95% CI 0.70–0.97, P = 0.02). Although most findings seen among all OR personnel were seen among nurses, they were often absent among surgeons.

Conclusions: Perception of OR safety of surgical practice was associated with hospital-level 30-day postoperative death rates.

*Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA

Department of Surgery, Massachusetts General Hospital, Boston, MA

South Carolina Hospital Association, Columbia, SC

§Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA

Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA.

Reprints: Sara J. Singer, PhD, MBA, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail:; Alex B. Haynes, MD, MPH, Ariadne Labs, 401 Park Drive, Third Floor East, Boston, MA 02215. E-mail:

This study was supported by grants from Agency for Healthcare Research and Quality (R18:HS019631-01) and the Branta Foundation.

Drs SJS and ABH contributed equally as coprincipal investigators.

Dr AAG reports potential conflicts of interest in an attached document. All other authors report no conflicts of interest.

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