Effect of an Office-based Surgical Safety System on Patient Outcomes

Noah M. Rosenberg, MD; Richard D. Urman, MD, MBA; Sean Gallagher, MD; John Stenglein, MD; Xiaoxia Liu, MS; Fred E. Shapiro, DO


ePlasty. 2012;12 

In This Article

Abstract and Introduction


Objective: To implement a customizable checklist in an interdisciplinary, team-based plastic surgery setting to reduce surgical complications.

Methods: We examined the effects on patient outcomes and documentation of a customizable, office-based surgical safety checklist. On the basis of the World Health Organization Surgical Safety Checklist, we developed a 28-element, perioperative checklist for use in the office-based surgical setting. The checklist was implemented in an office-based plastic surgery practice with an already high standard of care. We recorded baseline, prechecklist rates for each checklist item and postoperative adverse outcomes via a retrospective chart review of 219 cases. After an education program and 30-day run-in period, a prospective, post—checklist implementation chart review was initiated (n = 184), with outcome data compared to the baseline.

Results: The total number of complications per 100 patients decreased from 15.1 to 2.72 after checklist implementation (P < .0001), for an absolute risk reduction of 12.4. The proportion of patients with one or more complications decreased from 11.9% to 2.72% (P = .0006). Site and side marking increased from 69.9% prechecklist to 97.8% (P < .0001). Medical optimization increased from 90.9% to 99.5% (P < .0001). Emergency medical services (EMS) policy confirmation, case-specific equipment availability, anticipation of estimated blood loss, and verbal confirmation of local anesthetic toxicity precautions increased from 0% to 90.0% (P < .0001), 92.4% (P < .0001), 82.1% (P < .0001), and 91.3% (P < .0001), respectively. Assessment of patient satisfaction increased from 57.1% to 90.8% (P < .0001).

Conclusions: Implementation of a customizable checklist was associated with a reduction in surgical complications in an office-based plastic surgery practice with an already high standard of care.


In recent years, the economic pressures of medicine have incited a paradigm shift in health care delivery, such that surgical procedures are moving from the hospital to the office-based setting.[1] Safety in the office-based setting has been extensively studied.[2–5] Often called the "Wild West of health care," office-based practices are not uniformly regulated, and office-based procedures continue to increase at a rapid rate, with an estimated more than 10 million procedures performed in 2010.

Recent studies found that a comprehensive checklist used in an interdisciplinary, team-based setting resulted in reduced surgical complications and cost savings.[6–8] In particular, the SURPASS Trial showed that checklist implementation in hospitals reduced complications from 27.3 to 16.7 per 100 patients.[6] In addition, the Safe Surgery Saves Lives study group at the WHO found that checklist use in 8 hospitals around the world was associated with a reduction in major complications from 11.0% to 7.0%.[9]

Many checklist trials have been performed in hospitals, but the office-based setting remains relatively unstudied. A recent editorial pointed out that according to the Agency for Healthcare Research and Quality, only 10% of patient safety studies have been performed in outpatient settings; it concluded that the office-based patient safety is often "fragmented and disorganized and lacking in clear leadership," and the authors called for "creating a culture of safety."[1] This mounting concern about safety in the office-based setting led us to the development of an office-based surgical safety system that follows the office-based surgical pathway from taking a history and physical to assessing postoperative patient satisfaction. We evaluated the effect of this system on documentation, safety measures, and patient outcomes in a plastic surgery practice with a high baseline standard of care.