Safety in surgery: First steps towards a systems approach

The direct observation and assessment of surgical teams and the operative environment and examination of the entire process of care through record review, combined with comprehensive teaching and assessment of surgical technical skills, will we believe, greatly enhance our understanding of the key determinants of high performance in surgery and good clinical outcomes. Patient risk factors and surgical, anaesthetic and nursing skill will always be fundamental, but more subtle factors may be of particular importance when aiming for very high levels of performance. To put it crudely, good surgical skills coupled with basic team performance and basic equipment may enable a surgeon to achieve a 90% success rate in a high-risk operation. However, refinements in surgical skill may be a relatively small element in the drive to reduce mortality from 10% to 1%. Optimizing the pre- and postoperative care, the surgical environment, attention to ergonomics and equipment design, understanding the subtleties of decision making in a dynamic environment, enhancing communication and team performance may be more important than skill when reaching for truly high performance. Looking to the future, and the wider issues of patient safety, we believe that an open and comprehensive examination of the quality of care through out the patient-hospital interface and the performance of surgical teams and operative environment will be a powerful stimulus to safety culture and improvements in the wider healthcare system. © The Royal Society of Medicine Press Ltd 2005.