Published 3/1/2016
Michael S. Pinzur, MD

Assessment Program Improves Surgical Safety

Implementation of safety initiative a critical component of better care
In 1998, AAOS initiated an innovative patient safety program called Sign Your Site to help prevent wrong site surgery. The program expanded the focus of surgical patient safety from a retrospective evaluation of adverse events to a proactive implementation of safety processes intended to prevent them.

Lessons learned from aviation safety demonstrate that use of proactive initiatives such as surgical checklists can improve safety. As a result, many surgical organizations have adopted standardized, evidence-based, pre- and perioperative patient assessment and management tools to optimize patients prior to surgery and reduce the incidence of adverse events, thereby improving surgical outcomes and overall safety.

Leading healthcare systems use standardized patient care pathways for venous thromboembolism (VTE) prophylaxis, pain management, blood management, and accelerated activity and ambulation. Combined with regular collection of adverse events data, surgical processes and performance can be measured and improved.

A new methodology
Several years ago, Loyola University Health System, based in Maywood, Ill., adopted this methodology and since that time has experienced a substantially decreased mortality rate in geriatric patients who have sustained a hip or femur fracture. Under the Loyola program, surgical performance is continually assessed through data-mining of electronic health records, including evaluation of appropriate use and timeliness of interventions. Data are reported and reviewed on a regular basis by an orthopaedic safety/quality committee, with recommendations and feedback provided to surgical team members.

Supportive medical care now includes evaluation of preoperative patients by dedicated surgical internists responsible for a comprehensive assessment of medical comorbidities and optimization of modifiable risk factors prior to surgery. Known surgical safety risk factors such as diabetes, sleep apnea, anemia, deconditioning, cardiovascular disease, active smoking, VTE disease, active drug and alcohol use, neurocognitive disorders, and nutrition are diagnosed and optimally managed before the patient goes to surgery. Such innovations have improved the safety and outcomes of surgical care and decreased costs associated with treatments for adverse events.

Safety is critical
Safety grows in importance as healthcare systems increasingly focus on wellness and optimal chronic disease management. In some cases, providers may be obligated to assume risk for surgical care bundles that include all costs of care associated with a procedure, including treatments for adverse events during the episode of care. To improve care and reduce costs resulting from adverse events, collaboration between surgical and medical care teams is essential.

Patient safety is a critical and essential component of surgical quality and value, which seeks the best surgical outcome with the most efficient use of resources. Proactive patient safety programs decrease utilization of resources and cost of care, and ultimately lead to improved patient outcomes. As we see in so many facets of our lives, an ounce of prevention is often worth so much more than a pound of cure.

Michael S. Pinzur, MD, is a member of the AAOS Patient Safety Committee.


  1. Sign Your Site. January 1, 2003.
  2. Nance JJ: Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, MT, Second River Healthcare Press, 2008.
  3. Pinzur MS, Gurza E, Kristopaitis T, Monson R, Wall MJ, Porter A, Davidson-Bell V, Rapp T: Hospitalist–orthopaedic co-management of high risk patients undergoing lower extremity reconstruction surgery. Orthopedics 2009;32: 1-7. PMID: 19634848.
  4. American Academy of Orthopaedic Surgeons: Management of Hip Fractures in the Elderly: Evidence-Based Clinical Practice Guideline. Accessed September 3, 2015.
  5. Swart E, Vasudeva E, Makhni EC, Macaulay W, Bozic KJ: Dedicated perioperative hip fracture comanagement programs are cost-effective in high volume centers: An economic analysis. Clin Orthop Relat Res Epub: August 11, 2015.
  6. Society of Hospital Medicine: Quality & Innovation. Accessed September 11, 2015.
  7. Moucha CS, Clyburn T, Evans RP, Prokuski L: Modifiable risk factors for surgical site infection.  J Bone Joint Surg Am 2011;Feb 16; 93(4):398-404.
  8. Wukich DK, Lowery NJ, McMillen RL, Frykberg RG: Postoperative infection rates in foot and ankle surgery: A comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am 2010;92A:287-295.
  9. Boraiah S, Joo L, Inneh IA, Rathod P, Meftah M, Band P, Bosco JA, Iorio R: Management of modifiable risk factors prior to primary hip and knee arthroplasty. J Bone Joint Surg Am 2015;97A:1921-1928.