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Reducing the Burden of Surgical Harm: A Systematic Review of the Interventions Used to Reduce Adverse Events in Surgery

Howell, Ann-Marie MBBS*; Panesar, Sukhmeet S. MBBS*; Burns, Elaine M. PhD*; Donaldson, Liam J. FMedSci; Darzi, Ara FRS, FACS*,†

doi: 10.1097/SLA.0000000000000371

Objective: To perform a systematic review of interventions used to reduce adverse events in surgery.

Background: Many interventions, which aim to improve patient safety in surgery, have been introduced to hospitals. Little is known about which methods provide a measurable decrease in morbidity and mortality.

Methods: MEDLINE, EMBASE, and Cochrane databases were searched from inception to Week 19, 2012, for systematic reviews, randomized controlled trials (RCTs), and cross-sectional and cohort studies, which reported an intervention aimed toward reducing the incidence of adverse events in surgical patients. The quality of observational studies was measured using the Newcastle-Ottawa Scale. RCTs were assessed using the Cochrane Collaboration's tool for assessing risk of bias.

Results: Ninety-one studies met inclusion criteria, 26 relating to structural interventions, 66 described modifying process factors. Only 17 (of 42 medium to high quality studies) reported an intervention that produced a significant decrease in morbidity and mortality. Structural interventions were: improving nurse to patient ratios (P = 0.008) and Intensive Care Unit (ITU) physician involvement in postoperative care (P < 0.05). Subspecialization in surgery reduced technical complications (P < 0.01). Effective process interventions were submission of outcome data to national audit (P < 0.05), use of safety checklists (P < 0.05), and adherence to a care pathway (P < 0.05). Certain safety technology significantly reduced harm (P = 0.02), and team training had a positive effect on patient outcome (P = 0.001).

Conclusions: Only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement. It is important that future research remains focused on demonstrating a measurable reduction in adverse events from patient safety initiatives.

Supplemental Digital Content is Available in the Text.Many interventions, which aim to improve patient safety in surgery, have been introduced to hospitals. This systematic review analyzes studies that measure the benefit to the patient, in terms of reduced morbidity, mortality, and length of stay, due to surgical safety initiatives. A range of interventions are recommended.

*Department of Surgery and Cancer

Institute of Global Health Innovation, Imperial College, St Mary's Hospital, Praed Street, London, UK.

Reprints: Ann-Marie Howell, MBBS, Department of Surgery and Cancer, Imperial College, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom. E-mail:

Disclosure: All authors have completed the ICMJE (International Committee of Medical Journal Editors) disclosure form at A.M.H., E.B., L.D., and A.D. have been commissioned by and receive funding from the NHS Commissioning Board to implement an independent research and development program for the UK National Reporting and Learning System. The NHS Commissioning Board had no influence or role with respect to the submitted work. E.B. is supported by a CR-UK Clinical Lectureship (C42671/A13720), but the funders have no role with respect to this submitted manuscript. L.D. acts as the World Health Organization's (WHO) Patient Safety Envoy; this is an unfunded post and the WHO has no role with respect to this manuscript. Ethical approval was not required for this review. All data are available on request from the corresponding author.

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© 2014 by Lippincott Williams & Wilkins.