Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 205-207

Evolution of patient safety in surgery

Department of Vascular, Doncaster and Bassetlaw Teaching Hospital NHS Trust, Doncaster, England, UK

Date of Submission10-Aug-2020
Date of Acceptance11-Aug-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Sobhana Iftekhar Tani
Department of Vascular, Doncaster and Bassetlaw Teaching Hospital NHS Trust, Doncaster, England
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_115_20

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Medicine since its inception has continued to evolve. The past few decades have seen many specialties branching out. This is been to the increasingly complex nature of the field consequent to advances in technology and understanding of the human body. In addition to advancing technology, there is a relatively recent focus on safety. Studies have shown that there are a significant number of errors with serious consequences that occur among surgical patients. Many of these errors are preventable. Several factors play a role which includes nontechnical aspects such as human factors. This is most evident in high-pressure complex situations such as an operating theatre. This prompted the World Health Organization (WHO) to take up global patient safety challenges. With the motto of “Safe Surgery saves lives,” the WHO has undertaken numerous regional and global initiatives to improve patient safety and pioneered the implementation of the surgical safety checklist. Patient safety has evolved as an important part of surgical practice. This article presents a brief narrative of the development of patient safety in the surgery, its expansion, and future direction.

Keywords: Patient safety, safe surgery, surgical checklist, surgical complications

How to cite this article:
Tani SI, Haldipur N. Evolution of patient safety in surgery. Indian J Vasc Endovasc Surg 2021;8:205-7

How to cite this URL:
Tani SI, Haldipur N. Evolution of patient safety in surgery. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:205-7. Available from:

  Introduction Top

Worldwide it is estimated that 1 in every 25 human beings are undergoing an operation every year[1] and consequently, being exposed to the risks of surgical complications. In developed countries, the estimated risk of complications is about 3%–22%, which is higher in developing nations. A root cause analysis revealed that nearly half of these complications were preventable. They were attributed to errors in the health-care systems.[2],[3] Therefore, considering the number of people undergoing surgery in a year, it can be assumed surgical complications are a major cause of death and disability worldwide. This adds a significant burden on public health resources. Considering the global impact of preventable surgical complications, the burden they add to the health resources and the World Health Organization (WHO) chose “safety of surgical care” as their challenge in the second global patient safety challenge,[2] and published the Guidelines for Safe Surgery.

  The Concept of Patient Safety in Surgery Top

Emanuel et al., defined patient safety as a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery.[4] “To do no harm” is the simple dictum that underpins this goal. The goal of this concept is to minimize adverse events and preventable errors in health care. Professor Lucian Leap who is widely regarded as the father of the patient safety movement published a article called Error in medicine which elaborated the ensuring patient safety in healthcare.[5] Similarly, in the UK, “An organisation with a memory” highlighted patient safety issues in National Health Service (NHS). To Err Is Human: Building a Safer Health System, a ground-breaking report by the US Institute of Medicine resulted in raising further awareness on the impact of medical errors in the US healthcare.[6] This report also found that errors were not isolated, nor they were uncommon. It was highlighted that most errors are systemic in the healthcare industry and cannot be resolved at the level of individual health care providers. Hence, a systematic approach was needed to prevent errors from occurring, and preemptively identifying them when they do occur.

The goal of the WHO Patient Safety Safe Surgery Saves Lives Challenge was to improve the safety of surgical care around the world by identifying the key areas where intervention would have the maximum benefit in preventing errors inpatient care. The targeted four areas were surgical site infection prevention, safe anesthesia, safe surgical teams, and measurement of surgical services. It also recognized and highlighted that nontechnical skills in surgery such as teamwork, communication, and accountability are just as important to improve patient safety, as much as the surgical techniques.

  Patient Safety in Practice Top

To measure the standard of safety of surgical care around the world, a core set of safety standards needed to be defined first, so that it could be applied in all the countries, regardless of their infrastructure. The WHO Surgical Safety Checklist, a 19-item tool created by the WHO in association with the Harvard School of Public Health, is a simple tool which brings together the whole operating team to perform key safety checks during the perioperative care. All the items included on the checklist are supported by evidence that, if used reliably, can reduce complications from the surgery.

Between October 2007 and September 2008, the effect of the checklist was studied in multiple hospitals in a wide variety of health-care settings, economic circumstances, and diverse patient populations. The result of the study demonstrated dramatic improvements in processes and outcomes, the rate of major inpatient complications dropped from 11% to 7%, and the inpatient death rate following major operations fell from 1.5% to 0.8% after implementing the WHO checklist. The effect of the checklist in high and low/middle-income country sites showed similar results.[7] Not only did using the checklist reduced the rate of mortality and morbidity from surgical complications significantly, but it was also found to be cost saving.[2],[8] It helped to improve the nontechnical aspects such as communication in theatres. Team members after having a formal introduction were more likely to speak up when they have spotted an error. Ensuring simple practices such as site marking the side of the procedure to prevent wrong site operation, antibiotic prophylaxis in every sign in, time out, and sign out steps helps to prevent unwanted complication. Reading from the checklist for every case helped to ensure that teams consistently follow critical safety steps and minimize the most common avoidable risks in surgical patients.

Reporting near misses and untoward incidents is another step toward improving safety. Learning from the experiences of colleagues/other organizations goes a long way in reducing similar incidents in one's own practice. For this to be effective the prerequisites would include – a no-blame culture in the organization, openness, reducing hierarchy, honesty, and good tools for dissemination.

Surprisingly, despite being a high-risk profession safety in the surgery was not highlighted till recently. In the UK, the NHS only acquired a statutory duty of care of quality in 1998, unlike that of finance, which has been in existence for more than half a century. Clinical governance with the sole purpose of improving patient care within NHS is defined as “A framework through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.“[9]

It is often thought of in terms of the seven pillars of clinical governance-clinical effectiveness, risk management, patient experience and involvement, communication, resource effectiveness, strategic effectiveness, and learning effectiveness. The emphasis is on doing the right thing, at the right time, by the right person; the application of the best available evidence, involving the patient in the decision-making process, by an appropriately trained and resourced individual or team. It also encourages an atmosphere where in staff are valued, accountable, and need to continuously develop. External audit of processes and procedures also reduces potential risk. Having procedures or processes evaluates or risk assessed ensures that individually bring a fresh perspective and potentially improve quality.

  Current Challenges Top

There are currently more than 4000 hospitals in 122 countries that have registered as users of the WHO checklist, representing more than 90% of the world's population, with 1790 hospitals actively using the checklist.[8] This has been hailed as a brilliant innovative tool to aid in patient safety. Despite a lot of progress, there is still a lot of work need to be done. With more adaptation in different specialties, the WHO checklist may need to be modified to suit the need of that specialty. Changing mindset and shifting the blame culture is another hurdle in patient safety. Too often, an error is not reported in fear blame and appearing to be professional incompetent. The “Second Victim,” that is the health care professional responsible for the adverse event might also need support.[10] Instead of just blaming the cause of the event, the challenge is to learn from it and prevent it in the future from happening.

  Future of Patient Safety in Surgery Top

Patient safety is slowly but steadily gaining momentum and taking center stage in global health care. Patients themselves are playing a more critical role in this challenge, working in collaboration with health care professionals.[11] Training of doctors, nurses and health care professionals are being modulated by keeping patient safety in mind by ensuring proper supervision when required.[12]

The medical profession is learning and adapting practices from other high-pressure fields such as aviation. An example of which is learning from mistakes/near misses. National Reporting and Learning Service contains the largest database of adverse events in healthcare worldwide; to help health professionals to learn from each other's mistakes and prepare.

The checklist has been adapted to suite the need of various specialties. Such as, many vascular surgical departments added extra questions, ensuring the availability of the right graft/prosthesis or the radiographers to address the specific need of the specialties. The WHO checklist is also being implemented not only in surgical practice but other areas of intervention such as radiological procedures such as drainage, angiogram. In the future, this safety checklist can be modified and might be implemented not only in surgical sub-specialties, but also in other areas such as endoscopy, intensive care units, where interventions are performed, whether it be major or minor.[13]

  Conclusion Top

In a multifaceted, complex setting like healthcare, it might never be possible to completely eradicate errors. Over the past decade, patient safety has come into focus. Several initiatives to that end have proven that with a systematic approach the risk with unnecessary harms can be dramatically reduced. It is important to ensure all personnel involved in health care are involved in the process. Continuous progress and research in this field into different ideas is the key to improve the quality of care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet 2008;372:139-44.  Back to cited text no. 1
WHO. WHO Guidelines for Safe Surgery: Safe Surgery Saves Lives; c2008. Available from: [Last accessed on 2020 May 07].  Back to cited text no. 2
Kable A, Gibberd R, Spigelman AD. Adverse events in surgical patients in Australia. Int J Quality Health Care 2002;14:269-76.  Back to cited text no. 3
Emanuel L, Berwick D, Conway J, Combes J, Hatlie M, Leape L, et al. What Exactly Is Patient Safety? In: Henriksen K, Battles JB, Keyes MA, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008. Available from: [Last accessed on 2020 May 07].  Back to cited text no. 4
Leape LL. Error in medicine. JAMA 1994;272:1851-7.  Back to cited text no. 5
Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); c2000. Available from: [Last accessed on 2020 May 07].  Back to cited text no. 6
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.  Back to cited text no. 7
Walker IA, Reshamwalla S, Wilson IH. Surgical safety checklists: Do they improve outcomes? Br J Anaesthesia 2012;109:47-54.  Back to cited text no. 8
What is clinical governance? BMJ 2005;330:254.  Back to cited text no. 9
Neglecting the “second victim” will not help harmed patients or improve patient safety. BMJ 2019;365:L2167.  Back to cited text no. 10
Patient safety lessons from the world's experts. BMJ 2018;363:5211.  Back to cited text no. 11
Proposals for future training emphasise patient safety. BMJ 2009;339:3336.  Back to cited text no. 12
Kim FJ, da Silva RD, Gustafson D, Nogueira L, Harlin T, Paul DL. Current issues in patient safety in surgery: A review. Patient Saf Surg 2015;9:26.  Back to cited text no. 13


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