Perioperative Safety in Europe: Multi-Country Monitoring using Statistical Process Control

Background

Unsafe surgical care imposes a substantial burden on European healthcare systems, highlighting the need for effective patient safety improvement strategies. While Quality Improvement Collaboratives (QIC) are widely used to promote safer practices, robust monitoring is essential to ensure system performance. This study aimed to monitor the effect of a European multicountry QIC on adherence to Perioperative Patient Safety Practices (PPSP) and the prevalence of surgical complications.

Methods

A multicentre longitudinal study was conducted within the SAFEST project across 10 hospitals in five European countries (baseline: June 2023–May 2024; QIC: June 2024–November 2025). Monthly aggregated data on PPSP adherence and complication prevalence were analysed using Statistical Process Control (SPC) (P-charts), to detect common and special cause variation using standard SPC rules.

Results

Mean PPSP adherence was 61.1%. A sustained shift above the mean was observed from October 2024 to October 2025, with one point exceeding the upper control limit (UCL) in March 2025. However, a downward trend toward baseline occurred between March and August 2025. Surgical complications remained stable (mean=22.6%) until May 2025, followed by two points above the UCL in June and October 2025 (peak 34.3%), indicating deterioration. This was largely driven by “other” complications (peak 30.1%; UCL=23.8). Infections and cardiovascular complications remained stable within control limits, suggesting limited QIC’s impact on these outcomes.

Conclusions

The QIC produced measurable but unsustained improvements in PPSP adherence. Outcome stability and late deterioration highlight the complexity of achieving sustained safety gains. SPC proved valuable for monitoring, supporting timely identification of performance changes. Strengthening continuous monitoring and context-sensitive implementation is essential to achieve durable improvements in perioperative safety.

Key messages

• This QIC initially improved PPSP adherence, but sustaining those gains over time remained challenging.

• SPC enables real-time monitoring, revealing instability in processes and outcomes and supporting timely quality improvement actions.