The Problem:
69% of adverse events and deaths in health care are due to an error in management and thus are potentially preventable. Dr. Lucian Leape (MD, Adjunct Professor of Health Policy Harvard School of Public Health Boston, Massachusetts, USA) is a health policy analyst whose research has focused on error prevention and appropriateness of care, particularly prevention of medication errors. He has been a leading advocate of the nonpunitive systems approach to the prevention of medical errors and has led several studies of adverse drug events and their underlying systems failures.

Dr. Lucian Leape and colleagues have described these types of errors, which include diagnostic failures, treatment errors, errors in prevention, and others including communication failure and equipment failure. Some of these errors lead to perioperative infections, a major cause of patient injury, mortality, and health care cost. An estimated 2.6 percent of nearly 30 million operations are complicated by surgical site infections (SSIs) each year.

According to the CDC’s National Nosocomial Infections Surveillance(NNIS) system, which monitors reported trends in nosocomial infections in participating US acute care hospitals:
38% of all nosocomial infections in surgical patients are SSIs
4 to 16% of all nosocomial infections among all hospitalized patients are SSIs
2 to 5% of operated patients will develop SSI
SSI increases length of stay in hospital by an average of 7.5 days
$2,734 to $26,019 extra cost per SSI (1985, US dollars)
$130 million to $845 million per year estimated national costs in the USA
Better Models of Care Exist
Reducing surgical infections while minimizing antibiotic resistance remains a challenge to many health care institutions. Health care providers are faced with the additional challenge of trying to integrate new evidence-based infection prevention strategies, such as perioperative glycemic control, into practice. Enlightened management teams, regulatory agencies, health plan providers and purchasers, and medical associations need to provide the support required to create a culture of patient safety in our health care systems. With this support, informed, activated hospital teams can be empowered to make key changes to their subsystems (e.g., surgical units) and to incorporate safety considerations into their everyday work.