■ Safety of care:

Improving patient safety and reducing risks

Evaluating and implementing quality improvement initiatives in surgery

Originally published March 2018

The CMPA is committed to advancing safe surgical care. Surgical Safety in Canada [PDF]1, our 10-year review of surgical patient safety incidents—conducted in partnership with the Healthcare Insurance Reciprocal of Canada—noted that over half of all hospital safety incidents are related to surgical treatment and care. The report stressed that safe surgical care requires continued practice improvement and the implementation of reliable care processes.

Since Surgical Safety in Canada was released in 2016, many provinces have been making progress in introducing, implementing, or evaluating large-scale quality improvement initiatives. Positive experiences with established initiatives and the emergence of new technological approaches suggest that momentum is building around safer surgical care in Canada.

The following are examples of initiatives from across the country designed to improve surgical safety:

  • National Surgical Quality Improvement Program

    The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is an outcomes-based program designed to measure and compare the quality of surgical care across North America. In 2017, Ontario and BC—which have the largest number of participating hospitals—released evaluations of their NSQIP programs.2, 3 Ontario reported wide-scale enthusiasm for the program (with over 50 member hospitals), the identification of areas for improvement, and success in targeting indicators that fell below the benchmark. BC described stronger team cultures, reductions in adverse surgical outcomes, and reductions in length of stay. Both provinces noted the value of mentoring, learning, and collaborating that arose within participating hospitals.

  • Enhanced Recovery After Surgery

    Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach that uses evidence-based protocols to achieve early recovery after surgery. ERAS programs are in place in a number of provinces, and recent data indicate that there is reason to be optimistic about the approach. For example, reviews released by the BC Enhanced Recovery Collaborative,4 ERAS Alberta,5 and the McGill University Health Centre6 have shown that following the implementation of ERAS, complication rates and length of stay decreased for procedures such as colorectal surgery and pulmonary lobectomy. Enhanced Recovery Canada, a project led by the Canadian Patient Safety Institute, was created in 2017 and is now working to promote the adoption of ERAS principles nation-wide.

  • Operating Room Black Box®

    The Operating Room Black Box®,7 developed by Surgical Safety Technologies in Toronto, captures a range of information from within the operating room (including panoramic audiovisual data, physiological parameters from patients and healthcare professionals, and digital data from integrated devices, equipment, and sensors in the operating room). Aggregated data is analyzed and sent to participating hospitals in the form of reports that identify intra-operative risks and practices that promote safety. This year, the Operating Room Black Box® is being introduced at a number of Canadian hospitals, including North York General in Toronto and the Ottawa Hospital.

The CMPA supports quality improvement activities that have the potential to create safer surgical care and decrease adverse events. As with all quality improvement activities and process changes, including those involving the introduction of new technologies into medical practice, there are medical-legal issues that physicians need to consider. The CMPA has publications available discussing such issues, including surgical safety, the protection of quality improvement information and data from use in legal proceedings,8 and points to consider before adopting a new technology into practice.9 In addition to reviewing these publications, members are encouraged to contact the CMPA with any questions about surgical quality improvement initiatives.


  1. Canadian Medical Protective Association and Healthcare Reciprocal Insurance of Canada [Internet]. Ottawa (CA); CMPA;2016 May. Surgical Safety in Canada: A 10-year review of CMPA and HIROC medico-legal data [cited 2018 March 20]. Available from: https://www.cmpa-acpm.ca/static-assets/pdf/research-and-policy/system-and-practice-improvement/SSC_Detailed_Analysis_Report-e.pdf
  2. Health Quality Ontario [Internet]. Toronto; Health Quality Ontario;2017. Improving Surgical care in Ontario, The Ontario Surgical Quality Improvement Network [cited 2018 March 20]. Available from: http://www.hqontario.ca/Portals/0/documents/qi/onsqin/improving-surgical-care-in-ontario-en.pdf  
  3. BC Patient Safety & Quality Council [Internet]. Vancouver; BC Patient Safety & Quality Council;2017. Improved Outcomes = Improved Access [cited 2018 March 20]. Available from: https://bcpsqc.ca/documents/2017/11/2017-NSQIP-Report.pdf
  4. Specialist Services Committee, BC Enhanced Recovery Collaborative [Internet]. Vancouver (CA); BC Enhanced Recovery Collaborative;2016. BC Enhanced Recovery Collaborative: Final Report Highlights [cited 2018 March 20]. Available from: http://enhancedrecoverybc.ca/wp-content/uploads/2015/02/Final-Report_Highlights_Enhanced-Recovery-Collaborative_April-2016.pdf
  5. Nelson G, Kiyang LN, Crumley ET et al. Implementation of enhanced recovery after surgery (ERAS) across a provincial healthcare system: The ERAS Alberta colorectal surgery experience. World J Surg [Internet]. 2016 May [cited 2018 March 20];40(5):1092-103. Available from:  https://www.ncbi.nlm.nih.gov/pubmed/26928854
  6. Madani A, Fiore JF Jr, Wang Y, et al. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surgery [Internet]. 2015 Oct [cited 2018 March 20];158(4):899-908. Available from:  https://www.ncbi.nlm.nih.gov/pubmed/26189953 doi: 10.1016/j.surg.2015.04.046.
  7. Saegis, a subsidiary corporation and member of the CMPA family, has a business relationship with and interest in SST, the company that owns and operates the Operating Room Black Box.
  8. Canadian Medical Protective Association [Internet]. Ottawa (CA);CMPA;2009. Protection of quality improvement information [cited 2018 March 20]. Available from: https://www.cmpa-acpm.ca/en/research-policy/public-policy/protection-of-quality-improvement-information 
  9. Canadian Medical Protective Association [Internet]. Ottawa (CA);CMPA;2012. Technology unleashed: The evolution of online communication [cited 2018 March 20]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2012/technology-unleashed-the-evolution-of-online-communication

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.