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Deep Dive

ECRI and the Institute for Safe Medication Practices PSO: Strategies for Surgical Patient Safety

Systems Approach to Improving Outcomes and Reducing Risk

Register to receive the free Executive Brief of ECRI and the ISMP PSO’s ninth Deep Dive analysis on one of the most utilized areas of healthcare, surgical care.


Patients’ need for surgery drives a great deal of healthcare utilization. But when things go wrong during surgery, patients can experience serious harm.

Surgical care accounts for a large proportion of healthcare volume. In 2014, seven million inpatient hospital stays were for surgery, accounting for 20% of all inpatient stays (McDermott et al.). Annually, 35.8 million outpatient surgical procedures are performed in hospital-based outpatient settings and freestanding ambulatory surgery centers (Franklin Trust Ratings).

The volume of operative procedures, coupled with the potential for harm, makes surgical safety a paramount patient safety matter. About 14% of surgical patients in hospitals experience at least one adverse event (Anderson et al.). Risks include complications, infections, wrong-site surgery, and other mishaps. Even when patient harm does not occur, the complexity of operative procedures means that problems may have ripple effects, causing disruptions, delays, or other consequences for providers, staff, and patients. Some harmful events, such as retained items and certain complications (e.g., surgical- site infections), might not be discovered until much later, potentially increasing the magnitude of the harm.

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