Human Factors Engineering
Postoperative Surgical Complications
Surgical Site Infections
Infections after surgery are common and frequently lead to hospital readmission and other adverse consequences for patients. Recent programs, including several led by the Agency for Healthcare Research and Quality, have demonstrated how hospitals can successfully prevent these infections.
How a simple checklist can dramatically reduce medical errors.
Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.
This audio program features Peter Pronovost discussing his experience with checklist development and how it might be applied to support other quality improvement targets.
Identifying opportunities for quality improvement in surgical site infection prevention. Get Citation
Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Am J Infect Control. 2009;37:398-402.
This study conducted interviews with surgical division heads and managers of quality improvement and infection control at seven hospitals to highlight thematic strategies for preventing surgical site infections. The authors advocate for a combination of educational initiatives, performance data, explicit accountabilities that trigger action, and engaged champions to succeed in the team-oriented effort.
2009 National Patient Safety Goals. Get Citation
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
This commentary provides background on the development of the Joint Commission's 2009 National Patient Safety Goals and summarizes the goals set for the hospital environment.
Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. Get Citation
Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. JAMA. 2010;303:2479-2485.
Public reporting of quality measures is now widely used as a means of spurring hospitals to invest in patient safety and quality improvement efforts; however, it remains unclear if reported measures truly indicate a higher quality of care. In this study of more than 400,000 patients, researchers analyzed the relationship between adherence to recommended measures to prevent postoperative surgical infections and the subsequent development of such infections. They found that infection rates decreased only when all recommended interventions were carried out; performance of individual interventions did not seem to affect infection rates. Checklists—a relatively simple tool to ensure that all recommended steps of a process are carried out for every patient—initially gained fame as a means of preventing central line infections, and have subsequently been demonstrated to reduce surgical site infections.
Evaluating an evidence-based bundle for preventing surgical site infection. Get Citation
Anthony T, Murray BW, Sum-Ping JT, et al. Arch Surg. 2011;146:263-269.
Checklists of evidence-based interventions have resulted in notable successes in patient safety, particularly in preventing central line–associated bloodstream infections. This randomized controlled trial attempted to extend the checklist approach to prevention of surgical site infection. However, despite implementing five evidence-based practices in a bundled approach, the incidence of postoperative infections was actually higher in the intervention group compared with patients receiving standard infection prophylaxis. A commentary by the developers of the Keystone ICU checklist discusses the utility and limitations of checklists in improving safety.
Back to basics: preventing surgical site infections. Get Citation
Spruce L. AORN J. 2014;99:600-611.
Surgical site infections are a common yet preventable unintended consequence of surgery. This commentary describes strategies to reduce such infections, including hand hygiene adherence, checklist use, and speaking up when team members display poor compliance with best practices.
More than half a million heart surgery patients at risk of a dangerous infection.
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
Advances in perioperative quality and safety. Get Citation
Anderson KT, Appelbaum R, Bartz-Kurycki MA, Tsao K, Browne M. Semin Pediatr Surg. 2018;27:92-101.
Clinical skill development in surgery is evolving beyond technical expertise as focus has shifted to how teamwork and human factors affect safety. This commentary describes three key activities associated with surgical safety efforts, including monitoring surgical quality through national data analysis, bundling field-tested processes to prevent surgical site infections, and utilizing surgical checklists.