Reducing errors in surgical care: Theory and evidence

The last 5 years has seen considerable advancements in our understanding of the frequency, nature and causes of adverse events in healthcare. However, progress in reducing errors has been slow, in part because significant cultural change is difficult, and in part because empirical evidence about beneficial safety interventions is limited. This evidence is especially important in surgical care, where changes in practice are primarily led through scientific study. In this paper, we summarise the results of 5 years of work in evidence-based improvements in the quality of surgical care, firstly by investigating incident reporting systems, secondly by measuring and understanding the mechanisms of error in the operating theatre; thirdly by evaluating two interventions based on industrial best-practice (Team Resource Management from Aviation and Formula 1 pit-stops); and finally by reporting early the results of an intervention to improve quality of care on surgical wards.