Surgical audit: statistical lessons from Nightingale and Codman

There is a long history of interest in examining and comparing surgical outcomes. The 'epidemiological' approach was initiated by Florence Nightingale in her suggestion for uniform surgical statistics, and she clearly predicted the problems that are associated with collecting, analysing and interpreting such data. Unfortunately those responsible for implementing and reporting her scheme appeared not to have shared her insight. The contrasting 'clinical' approach was championed by Ernest Codman in his search for full and honest appraisals of surgical errors. Once again, despite initial enthusiasm, others had great difficulty in following his example, although we discuss a recent instance of a reflective analysis of an individual surgeon's performance. We conclude by suggesting that a synthesis between these approaches is appropriate, but we follow others in warning of the inevitable extra-statistical difficulties that will arise.