Patient safety and quality in surgery

Patient safety is of fundamental concern to the practicing surgeon, yet the deficiencies of our health care system in providing the degree of safety achieved by other industries are only relatively recently appreciated. Ernest Amory Codman joined the Massachusetts General Hospital staff in 1895, became interested in improving patient outcomes, and proposed the "end result idea", which would involve patient follow-up for 1 year after hospitalization. He also advocated public disclosure of outcomes by surgeons and hospital [1]. Eventually his efforts earned him pariah status. The American College of Surgeons has stood for patient safety since its establishment in 1913. Interestingly, it founded a hospital care standards program, which eventually became the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). It also formed the Committee on Cancer and the Committee on Trauma to improve the surgical care of cancer and trauma patients [2]. Safety as a system-related concern was recognized after studies of industrial catastrophes, such as major airline accidents and the Three Mile Island nuclear reactor accident in the 1970s [3,4]. In the early 1990s, medical error resulting in patient injury or death began to be appreciated as more than rare [5]. The 1999 publication by the Institute of Medicine, To Err is Human, estimated that between 44,000 and 98,000 patients die annually in the United States as a direct result of medical error [6]. This prompted the recognition that safety problems were real and pervasive. In addition to safety concerns, data such as are published in The Dartmouth Atlas of Health Care have focused attention on the unexplained regional variations in health care in the United States [7]. As health care costs have risen, payers, insurers, and consumers are keenly aware of these issues and seek solutions. Our professional responsibility is to lead the movement toward safer and higher quality health care for our patients, first in surgery, but also throughout our practices and institutions.