The SAGES Manual of Quality Outcomes and Patient Safety 2nd Edition John R Romanelli Jonathan M Dort Rebecca B Kowalski Prashant Sinha

The SAGES Manual of Quality
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Editors
John R. Romanelli, Jonathan M. Dort, Rebecca B. Kowalski and
Prashant Sinha
The SAGES Manual of Quality, Outcomes

and Patient Safety
2nd ed. 2022
Editors
John R. Romanelli
Department of Surgery, University of Massachusetts Chan Medical
School - Baystate, Medical Center, Springfield, MA, USA
Jonathan M. Dort
Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA,
USA
Rebecca B. Kowalski
Department of Surgery, Lenox Hill Hospital, New York, NY, USA
Prashant Sinha
Department of Surgery, NYU Langone Medical Center, Brooklyn, NY, USA
ISBN 978-3-030-94609-8 e-ISBN 978-3-030-94610-4

https://doi.org/10.1007/978-3-030-94610-4
© SAGES 2022
This work is subject to copyright. All rights are solely and exclusively
licensed by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in
any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks,

service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.
The publisher, the authors, and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
material contained herein or for any errors or omissions that may have
been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer

Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham,
Switzerland
Preface
The idea that we can continually improve our outcomes in the delivery
of healthcare is intrinsic in the nomenclature of calling what we do
being in “practice.” The concept of improving quality in the practice of
medicine dates back to the nineteenth century. From Ignaz
Semmelweis’ seminal work on handwashing to prevent puerperal
sepsis to Florence Nightingale associating high death rates of soldiers in
Army hospitals with poor living conditions, physicians and other
healthcare providers have often endeavored to find novel ways to
improve the delivery of patient care. In surgery, Ernest Codman is
credited with the first efforts in quality improvement, recognizing that
surgeons could learn from each other and share science to lead to
better outcomes for patients, and so he helped found the American
College of Surgeons (ACS). Dr. Codman helped to start the Hospital
Standardization Program at the ACS, which created and oversaw
hospital standards. Today, this is known as the Joint Commission, which
is ubiquitous in the healthcare quality arena. He also is the father of
implementation of strategies to improve healthcare outcomes. Surgical
quality, outcomes, and safety owe a debt of gratitude to this unique
surgeon with remarkable foresight over a century ago.
While surgical societies such as ACS or the Society of Thoracic
Surgeons (STS) have often led the charge to quality improvement,
SAGES, too, has long had a role in this space. SAGES proudly developed
the Fundamentals of Laparoscopic Surgery (FLS), the Fundamentals of
Endoscopic Surgery (FES), and the Fundamentals of the Use of Safe
Energy (FUSE); these programs were borne of the concept of education
and accreditation of surgeons as “safe” for their patients; both FLS and
FES are requirements for all graduating surgical residents. The SAGES
Quality, Outcomes, and Safety (QOS) Committee was formed as a Task
Force on Outcomes in 1997, and it eventually led to the creation of the
Outcomes Committee in 2003. This committee was expanded into the
QOS Committee in 2008, and it leads the society and its 7000+ surgeons
and members as more public attention is devoted to healthcare quality.
The first edition of the SAGES Quality, Outcomes, and Safety Manual
was groundbreaking as it combined didactic study with expert opinion,
venturing outside the clinical arena with important writings on topics
such as systems improvement, perioperative safety, error analysis,
simulation as an educational tool, team training, and an emphasis on
the SAGES Fundamentals programs. Published in 2011, this manual
edited by David Tichansky, John Morton, and Daniel B. Jones was one of
the first scholarly texts to collect these thoughts into one book, and it
was well received by the SAGES membership and surgeons around the
world.
Much has transpired in the last decade, and the editors of the
second edition of the SAGES Quality, Outcomes, and Safety Manual
sought to include these topics for discussion. So, while we sought to
keep and update some of the fine work of the first edition, we added
new sections that are timely and relevant to the surgeon in practice
today. We explored areas of enhanced recovery pathways and the
avoidance of postoperative opioid use, as the crisis of the abuse of the
drugs is widespread and perhaps preventable to some degree. We
examined threats to quality, such as healthcare disparities, disruptive
behavior, physician wellness and burnout, physicians as second victims
of bad outcomes, ergonomics of surgery, and training new surgeons in
the era of work hour limitations. We discussed pathways towards
quality, such as mentoring, teleproctoring, training to proficiency, and
creating procedural benchmarks. We debated controversial issues such
as the use of the robot in minimally invasive surgery, prevention of bile
duct injury, super-specialization of general surgery and what it means
for patients, and non-clinical concerns such as enforced OR attire and
consistent operating room teams. And wherever possible, we
highlighted the role that SAGES plays in the quality, outcomes, and
safety space.
Lastly, it would be remiss of me personally and professionally not to
acknowledge the incredible work of Erin Schwarz. Erin is the
administrative staff member who ensures that Quality, Outcomes, and
Safety continues its important role in SAGES. A textbook project of this
magnitude simply would not be possible without her indefatigable
efforts to keep the momentum going to complete this project. Erin is a
key member of BSC, who are the framework upon which SAGES thrives.
My heartfelt gratitude goes to the whole of BSC, but to Erin, I can only
humbly say “thank you.”
On behalf of my co-editors, Jonathan Dort, Rebecca Kowalski, and
Prashant Sinha, I thank you for reading this book and hope it helps you
to consider important concepts to improve the care of your surgical
patients.
John R. Romanelli
Springfield, MA, USA
Preface
Approximately a decade following the publication of the first edition of
this manual, the world of surgery continues to dramatically change. The
focus on the quality of care provided by surgeons, the safety of the
patients we treat, and the clinical outcomes we see as a result of our
care, by both the surgical community and the public, has never been
stronger. SAGES remains committed to leading in these areas, and the
work and expertise presented in this manual will hopefully serve as a
comprehensive resource to all of our SAGES members, as well as to the
broader surgical community. This manual covers a wide range of
critical topics, from the language and basics of quality, outcomes, and
patient safety to education, mentorship, new technologies, and different
approaches to care. It is crucial for the care of their patients that
surgeons understand all of the elements of how quality is measured,
how care outcomes are reviewed, and what the best practices available
to them are on how to provide that care. On behalf of the SAGES Quality,
Outcomes, and Patient Safety Committee, I am indebted to the time and
efforts of the committee members and authors who have helped to
create this manual. I also wish to thank my co-editors, John Romanelli,
Rebecca Kowalski, and Prashant Sinha, as well as to Erin Schwarz, who
has provided all of the administrative support to this endeavor, for all of
their hard work in producing this second edition. I hope that you find it
to be informative, comprehensive, and useful.
Jonathan M. Dort
Falls Church, VA, USA
Contents
Part I Surgical Quality
1 Defining Quality in Surgery
Ryan Howard and Justin B. Dimick
2 Never Events in Surgery
Anjali A. Gresens and Jacob A. Tatum
3 Creating a Surgical Dashboard for Quality
Samuel M. Miller and John M. Morton
4 Understanding Complex Systems and How It Impacts Quality in
Surgery
Buğ ra Tugertimur and Bruce Ramshaw
5 Clinical Care Pathways
Michael R. Keating and Benjamin E. Schneider
6 Tracking Quality:Data Registries
Brenda M. Zosa and Anne O. Lidor
7 Accreditation Standards:Bariatric Surgery
Teresa L. LaMasters, Jamie P. Loggins and Teresa Fraker
8 Resident Evaluation and Mentorship:Milestones in Surgical
Education
Ingrid S. Schmiederer and James N. Lau
9 Implementing Quality Improvement at Your Institution
Michael Ghio, Danuel Laan and Shauna Levy
10 Creating and Defining Quality Metrics That Matter in Surgery
Anai N. Kothari and Thomas A. Aloia
11 The Role of Surgical Societies in Quality
Benjamin J. Flink and Aurora D. Pryor
Part II Surgical Outcomes
12 Perioperative Risk Assessment
Gina Adrales and Swathi Reddy
13 The Current State of Surgical Outcome Measurement
Brian J. Nasca, Jonah J. Stulberg, Marylise Boutros and
Jeongyoon Moon
14 Developing Patient-Centered Outcomes Metrics for Abdominal
Surgery
Julio F. Fiore, Fateme Rajabiyazdi and Liane S. Feldman
15 Enhanced Recovery Protocols:A Toolkit for Success
Deborah S. Keller
16 Perioperative Pain Management for Abdominal Operations
Tonia M. Young-Fadok
17 Classification and Analysis of Error
Cara A. Liebert and Sherry M. Wren
18 Disclosure of Complications and Error
Rocco Orlando III and Stephanie Calcasola
19 Avoidance of Complications
Prashant Sinha
20 Safe Introduction of Technology
Kathleen Lak
Part III Surgical Safety
21 Quality, Safety, and the Electronic Health Record (EHR)
Eunice Y. Huang and Gretchen Purcell Jackson
22 Checklists, Surgical Timeout, Briefing, and Debriefing:Safety in
the Operating Room
Amelia T. Collings and Dimitrios Stefanidis
23 Creating Effective Communication and Teamwork for Patient
Safety
Pascal Fuchshuber and William Greif
24 Energy Safety in the Operating Room
Timothy Fokken and Sharon Bachman
25 Patient Safety Indicators as Benchmarks
Stacy M. Ranson and Jonathan M. Dort
26 Culture of Safety and Era of Better Practices
Eileen R. Smith and Shaina R. Eckhouse
27 Learning New Operations and Introduction into Practice
Ugoeze J. Nwokedi, Lee Morris and Nabil Tariq
Part IV Working Towards Surgical Quality, Outcomes, and Safety
28 Team Training
John T. Paige
29 Simulation and OR Team Performance
Jaisa Olasky and Daniel B. Jones
30 Debriefing After Simulation
Brandon W. Smith and Neal E. Seymour
31 Using Simulation for Disclosure of Bad News
Limaris Barrios
32 Teleproctoring in Surgery
Julio Santiago Perez and Shawn Tsuda
33 Training for Quality:Fundamentals Program
Sofia Valanci and Gerald M. Fried
34 Training to Proficiency
Madhuri B. Nagaraj and Daniel J. Scott
35 The Critical View of Safety:Creating Procedural Safety
Benchmarks
William C. Sherrill III and L. Michael Brunt
36 Mentorship and Quality in Surgery
Dina Tabello and Jonathan M. Dort
Part V Threats to Surgical Quality, Outcomes, and Safety
37 Disparities in Healthcare:The Effect on Surgical Quality
Valeria S. M. Valbuena and Dana A. Telem
38 Surgeon Wellness:Scope of the Problem and Strategies to Avoid
Burnout
John R. Romanelli
39 The Disruptive Surgeon
M. Shane Dawson and Rebecca B. Kowalski
40 The Surgeon as Collateral Damage:The Second Victim
Phenomenon
Rebecca Gates and Charles Paget
41 The Surgeon in Decline:Can We Assess and Train a Surgeon as
Their Skills Deteriorate?
Arthur Rawlings
42 Fatigue in Surgery:Managing an Unrealistic Work Burden
V. Prasad Poola, Adam Reid and John D. Mellinger
43 Training New Surgeons:Maintaining Quality in the Era of Work
Hour Regulations
Ingrid S. Schmiederer and James R. Korndorffer Jr
44 Maintaining Surgical Quality in the Setting of a Crisis
John R. Romanelli
45 Ergonomic Considerations for Surgeon Physical Wellness
Marinda Scrushy and Diana L. Diesen
Part VI Surgical Controversies That Impact Quality
46 Hernia Repair:Robot or No Robot?
Matthew Madion and Rana M. Higgins
47 The Consistent Operating Room Team
Leena Khaitan and Joseph Youssef
48 Prevention of Common Bile Duct Injury:What Are we as
Surgeons Doing to Prevent Injury
Nabajit Choudhury, Manoj Kumar Choudhury and
Rebecca B. Kowalski
49 OR Attire:Does it Impact Quality?
Yasmin Essaji, Kelly Mahuron and Adnan Alseidi
50 Learning When Not to Operate:From Patient Selection to
Withdraw of Care
Carolyn Judge, Kim Gerling and Tiffany C. Cox
51 The Changing Paradigm in Acute Care Surgery:Who Is the Best
to Offer the Care?
Freeman Condon and Robert Lim
52 Super-subspecialization of General Surgery:Is This Better for
Patients?
Joseph A. Sujka and Christopher G. DuCoin
53 What Is the Connection Between Physician Relationships with
Industry and Patient Care?
Caroline E. Reinke, Peter M. Denk, Erin Schwarz and
Phillip P. Shadduck
Index
Contributors
Gina Adrales
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Thomas A. Aloia
University of Texas MD Anderson Cancer Center, Houston, TX, USA
Adnan Alseidi
Department of Surgery, University of California San Francisco, San
Francisco, CA, USA
Sharon Bachman
USA
Limaris Barrios
Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova
Southeastern University in Florida, Fort Lauderdale, FL, USA
Marylise Boutros
Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish
General Hospital, Montreal, QC, Canada
L. Michael Brunt
Department of Surgery and Section of Minimally Invasive Surgery,
Washington University School of Medicine, St. Louis, MO, USA
Stephanie Calcasola
Hartford HealthCare, Hartford, CT, USA
Manoj Kumar Choudhury

Senior Consultant, GI and MIS, Nemcare Superspecialty Hospital,
Assam, India
Nabajit Choudhury
The University of Tennessee Health Science Center, Memphis, TN, USA
Freeman Condon
Tripler Army Medical Center, Honolulu, HI, USA
Tiffany C. Cox
Department of Surgery, Uniformed Services University of Health
Sciences & Walter Reed National Military Medical Center, Bethesda, MD,
USA
M. Shane Dawson
Northwell Health at Lenox Hill Hospital, New York, NY, USA
Peter M. Denk
GI Surgical Specialists, Fort Myers, FL, USA
Diana L. Diesen
Department of Surgery, University of Texas Southwestern Medical
Center, Dallas, TX, USA
Justin B. Dimick
Department of Surgery, University of Michigan, Ann Arbor, MI, USA
Jonathan M. Dort
USA
Christopher G. DuCoin
Department of Surgery, University of South Florida Morsani College of
Medicine, Tampa, FL, USA
Shaina R. Eckhouse
Section of Minimally Invasive Surgery, Department of Surgery,
Washington University School of Medicine, Saint Louis, MO, USA
Yasmin Essaji
Division of HPB Surgery, Virginia Mason Medical Center, Seattle, WA,
USA
Liane S. Feldman
Department of Surgery, McGill University, Montreal, QC, Canada
Julio F. Fiore
Department of Surgery, McGill University, Montreal, QC, Canada
Benjamin J. Flink
Stony Brook University Department of Surgery, Division of Bariatric,
Foregut, and Advanced Gastrointestinal Surgery, Stony Brook, NY, USA
Timothy Fokken
USA
Teresa Fraker
Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP), Division of Research and Optimal
Patient Care (DROPC), American College of Surgeons (ACS), Chicago, IL,
USA
Gerald M. Fried
Professor of Surgery and Associate Dean for Education Technology and
Innovation, Montreal, QC, Canada
Faculty of Medicine and Health Sciences, McGill University, Montreal,
QC, Canada
Director, Steinberg Centre for Simulation and Interactive Learning,
Faculty of Medicine and Health Sciences, McGill University, Montreal,
QC, Canada
Pascal Fuchshuber
Sutter East Bay Medical Group, UCSF-East Bay, Oakland, CA, USA
Rebecca Gates
Virginia Tech Carilion School of Medicine and Carilion Clinic, Roanoke,
VA, USA
Kim Gerling
USA
Michael Ghio
Tulane University School of Medicine & Tulane Medical Center, New
Orleans, LA, USA
William Greif
The Permanente Medical Group, Kaiser Walnut Creek Medical Center,
Walnut Creek, CA, USA
Anjali A. Gresens
Bariatric Surgery, Sentara Medical Group, Norfolk, VA, USA
Department of Surgery, Eastern Virginia Medical School, Norfolk, VA,
USA
Rana M. Higgins
Medical College of Wisconsin, Milwaukee, WI, USA
Ryan Howard
Department of Surgery, University of Michigan, Ann Arbor, MI, USA
Eunice Y. Huang
Departments of General and Thoracic Surgery, Monroe Carell Jr.
Children’s Hospital at Vanderbilt, Nashville, TN, USA
Gretchen Purcell Jackson

Departments of General and Thoracic Surgery, Monroe Carell Jr.
Children’s Hospital at Vanderbilt, Nashville, TN, USA
Intuitive Surgical, Sunnyvale, CA, USA
Daniel B. Jones
Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ,
USA
Carolyn Judge
USA
Michael R. Keating
University of Texas Southwestern, Dallas, TX, USA
Deborah S. Keller
Division of Colorectal Surgery, Department of Surgery, University of
California at Davis, Sacramento, CA, USA
Leena Khaitan
University Hospitals, Department of Surgery, Cleveland, OH, USA
James R. Korndorffer Jr
Department of Surgery, Stanford University School of Medicine,
Stanford, CA, USA
Anai N. Kothari
Department of Surgery, Division of Surgical Oncology, Medical College
of Wisconsin, Milwaukee, WI, USA
Rebecca B. Kowalski
Northwell Health at Lenox Hill Hospital, New York, NY, USA
Danuel Laan
Orleans, LA, USA
Kathleen Lak
Bariatric and Minimally Invasive Gastrointestinal Surgery, Medical
College of Wisconsin, Milwaukee, WI, USA
Teresa L. LaMasters
Iowa Methodist Medical Center Unity Point Clinic, University of Iowa,
Des Moines, IA, USA
James N. Lau
Loyola University Medical Center, Department of Surgery, Maywood, IL,
USA
Shauna Levy
Orleans, LA, USA
Anne O. Lidor
Department of Surgery, Johns Hopkins University SOM, Baltimore, MD,
USA
Cara A. Liebert
Department of Surgery, Stanford University School of Medicine, VA Palo
Alto Health Care System, Palo Alto, CA, USA
Robert Lim
University of Oklahoma School of Medicine Tulsa, Tulsa, OK, USA
Jamie P. Loggins
Mission Weight Management Center, Asheville, NC, USA
Matthew Madion
Medical College of Wisconsin, Milwaukee, WI, USA
Kelly Mahuron
Department of Surgery, University of California San Francisco, San
Francisco, CA, USA
John D. Mellinger
Southern Illinois University School of Medicine, Department of Surgery,
Springfield, IL, USA
Samuel M. Miller
Department of Surgery, Yale School of Medicine, New Haven, CT, USA
Jeongyoon Moon
Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish
General Hospital, Montreal, QC, Canada
Lee Morris
Department of Surgery, The Houston Methodist Hospital, Houston, TX,
USA
John M. Morton
Department of Surgery, Yale School of Medicine, New Haven, CT, USA
Madhuri B. Nagaraj
University of Texas Southwestern, Department of Surgery, Dallas, TX,
USA
Brian J. Nasca
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Ugoeze J. Nwokedi
USA
Jaisa Olasky
Mount Auburn Hospital, Harvard Medical School, Boston, MA, USA
Rocco Orlando III

Hartford HealthCare, Hartford, CT, USA
University of Connecticut School of Medicine, Hartford, CT, USA
Charles Paget
Virginia Tech Carilion School of Medicine and Carilion Clinic, Roanoke,
VA, USA
John T. Paige
Department of Surgery, MedicineLouisiana State University (LSU)
Health New Orleans School of Medicine, New Orleans, LA, USA
Julio Santiago Perez

Valley Health System General Surgery Department, Las Vegas, NV, USA
V. Prasad Poola
Aurora D. Pryor
Stony Brook University Department of Surgery, Division of Bariatric,
Foregut, and Advanced Gastrointestinal Surgery, Stony Brook, NY, USA
Fateme Rajabiyazdi
Department of Systems and Computer Engineering, Carleton University,
Ottawa, ON, Canada
Bruce Ramshaw
Managing Partner, CQInsights PBC, Knoxville, TN, USA
Stacy M. Ranson
Inova Fairfax Medical Campus, Falls Church, VA, USA
Arthur Rawlings
General Surgery, University of Missouri, One Hospital Drive, Columbia,
MO, USA
Swathi Reddy
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Adam Reid
Caroline E. Reinke
Department of Surgery, Atrium Health, Charlotte, NC, USA
Amelia T. Collings
Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
John R. Romanelli
Department of Surgery, University of Massachusetts Chan Medical
School - Baystate Medical Center, Springfield, MA, USA
Ingrid S. Schmiederer
Department of Surgery, Stanford University School of Medicine,
Stanford, CA, USA
New York Presbyterian-Queens, Department of Surgery, Flushing, NY,
USA
Benjamin E. Schneider
University of Texas Southwestern, Dallas, TX, USA
Erin Schwarz
SAGES, Los Angeles, CA, USA
Daniel J. Scott
University of Texas Southwestern, Department of Surgery and
Simulation Center, Dallas, TX, USA
Marinda Scrushy
Department of Surgery, University of Texas Southwestern Medical
Center, Dallas, TX, USA
Neal E. Seymour
Baystate Medical Center, Department of Surgery, Springfield, MA, USA
Phillip P. Shadduck
Duke University, Durham, NC, USA
William C. Sherrill III

Department of Surgery and Section of Minimally Invasive Surgery,
Washington University School of Medicine, St. Louis, MO, USA
Prashant Sinha
Department of Surgery, NYU Langone Medical Center, Brooklyn, NY, USA
Brandon W. Smith
Baystate Medical Center, Department of Surgery, Springfield, MA, USA
Eileen R. Smith
Section of Minimally Invasive Surgery, Department of Surgery,
Washington University School of Medicine, Saint Louis, MO, USA
Dimitrios Stefanidis
Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
Jonah J. Stulberg
The University of Texas Health Science Center at Houston, Houston, TX,
USA
Joseph A. Sujka
Department of Surgery, University of South Florida Morsani College of
Medicine, Tampa, FL, USA
Dina Tabello
Inova Fairfax Medical Campus, Falls Church, VA, USA
Nabil Tariq
USA
Jacob A. Tatum
Department of Surgery, Eastern Virginia Medical School, Norfolk, VA,
USA
Dana A. Telem
National Clinician Scholars Program, University of Michigan, Ann Arbor,
MI, USA
Shawn Tsuda
Valley Health System General Surgery Department, Las Vegas, NV, USA
Buğra Tugertimur
General Surgery Resident, PGY 5, Department of Surgery, Lenox Hill
Hospital, Northwell Health, New York City, NY, USA
Sofia Valanci
Doctoral student in Experimental Surgery, Education Concentration,
McGill University, Montreal, QC, Canada
Valeria S. M. Valbuena
University of Michigan, Department of Surgery, Ann Arbor, MI, USA
Sherry M. Wren
Department of Surgery, Center for Innovation and Global Health,
Stanford University School of Medicine, VA Palo Alto Health Care
System, Palo Alto, CA, USA
Tonia M. Young-Fadok
Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, AZ, USA
Joseph Youssef
University Hospitals, Department of Surgery, Cleveland, OH, USA
Brenda M. Zosa
Department of Surgery, Johns Hopkins University SOM, Baltimore, MD,
USA
Part I
Surgical Quality
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
J. R. Romanelli et al. (eds.), The SAGES Manual of Quality, Outcomes and Patient Safety
https://doi.org/10.1007/978-3-030-94610-4_1
1. Defining Quality in Surgery

Ryan Howard1 and Justin B. Dimick1
(1) Department of Surgery, University of Michigan, Ann Arbor, MI, USA
Justin B. Dimick
Email: [email protected]
Introduction
With recognition of wide variations in surgical performance, demand
for information on surgical quality is at an all-time high. Patients and
families are turning to their physicians, hospital report cards, and the
Internet to identify the safest hospitals for surgery [1]. Payers and
purchasers are using efforts to reward high quality (e.g., pay for
performance) or steer patients toward the highest quality providers
(e.g., selective referral) [2]. In addition to responding to these external
demands, providers are becoming more involved in leveraging their
own quality measurement platforms to improve surgical care, such as
the National Surgical Quality Improvement Program (NSQIP) [3].
Finally, professional organizations are now accrediting hospitals based
on their ability to meet certain metrics believed to be associated with
better outcomes [4].
Despite the need for good measures of quality in surgery, there is
very little agreement about how to best assess surgical performance.
According to the widely used Donabedian paradigm, quality can be
measured using various aspects of structure, process, or outcome [5].
In addition, many widely recognized quality measurement efforts, such
as those by the Leapfrog group, use composite, or “global,” measures of
quality, which combine one or more elements of structure, process, and
outcome [6]. In this chapter, we consider the advantages and
disadvantages of each type of quality measure. We close by making
recommendations for choosing among these different approaches.
Structure
The structure of surgical care refers to measurable attributes of a
hospital (e.g., size and volume) or its providers (e.g., specialty training
and years in practice) (Table 1.1). Measures of structure are extensively
used in the measurement of surgical quality, owing to their widespread
availability. The American College of Surgeons (ACS) and the American
Society of Metabolic and Bariatric Surgeons (ASMBS) accredit hospitals
for bariatric surgery based largely on measures of structure, including
hospital volume, surgeon volume, and other structural elements
necessary for providing multidisciplinary care for the morbidly obese
[4].
Table 1.1 Approaches to measuring the quality of care for aortic surgery with
advantages and disadvantages of each approach
Type of Example Advantages Disadvantages

measure
Structure Hospital or surgeon Inexpensive and Not actionable for
volume readily available quality improvement
Good proxy for Not good for
outcomes discriminating among
individual providers
Process Prophylactic antibiotics Actionable as Known processes relate
given on time targets for to unimportant or rare
Adherence to venous improvement surgical outcomes
thromboembolism Less influenced by Very few “high leverage”
prevention guidelines patient risk and processes of care are
random errors known
Outcomes Anastomotic leak rates Seen as the Sample sizes often too
with bariatric surgery bottom line of small at individual
Wound infection with patient care hospitals
ventral hernia repair Enjoy good “buy- Need for detailed data
in” from surgeons for risk adjustment
Type of Example Advantages Disadvantages
measure
Composite Leapfrog group’s Addresses Not granular enough to
“Survival Predictor” problems with identify specific clinical
small sample size areas that need
Makes sense of improvement
multiple
conflicting
measures
Structural elements have several key strengths as quality measures.
First, they are relatively easy to ascertain. Often, structural elements
such as volume can be obtained from readily available administrative
data. Second, many structural measures are strong predictors of
hospital and surgeon outcomes. The most well-known example of this
relationship was described by Birkmeyer et al., who observed a fivefold
difference in mortality between low- and high-volume hospitals for
high-risk surgical procedures [7]. This same relationship holds true for
individual surgeon volume as well [8]. Since the early 2000s, the
volume-outcome relationship has been demonstrated for dozens of
operations [9].
However, there are certain limitations of using structural quality
measures. Most importantly, they are proxies for quality rather than
direct measures. As a result, they only hold true on average. For
example, while high-volume surgeons are better than low-volume
surgeons on average, there are likely to be some high-volume surgeons
with bad outcomes and low-volume surgeons with good outcomes [5].
What’s more, structural measures are not meaningfully actionable for
quality improvement. Hospitals cannot easily change their operative
volume, although regionalization of high-risk care may offer a solution
to centralize care at more specialized centers and leverage the volume-
outcome relationship.
In recent years, structural measures of care have also been found to
be lacking when implemented as real-world quality metrics. For
example, after certain high-risk cancer operations, there was no
mortality difference in hospitals that met the Leapfrog group’s
minimum volume standards and those that did not [10]. Similarly, even
among hospitals designated as bariatric centers of excellence based on
volume standards, there is still a 17-fold difference in rates of serious
complications [11].
Process
Processes of care are the steps and details of a patient’s care that can
lead to good (or bad) outcomes. Although processes of care can
represent details of care in the preoperative, intraoperative, and
postoperative phases, the most familiar process measures focus on
details in the immediate preoperative phase of patient care. For
example, the Center for Medicare and Medicaid Services (CMS) Surgical
Care Improvement Project (SCIP) measures utilization of preoperative
antibiotic and venous thromboembolism prophylaxes. Along these
lines, one of the most familiar approaches to improving the process of
care in surgery is the use of a presurgical checklist, which verifies that a
number of best practices (confirming patient name, procedure
laterality, administration of antibiotics, etc.) have been performed [12].
This has now become standard practice in the United States.
Process measures have several strengths as quality measures (Table
1.1). First, processes of care are extremely actionable in quality
improvement. When hospitals and surgeon are “low outliers” for
process compliance (e.g., patients not getting timely antibiotic
prophylaxis), they know exactly where to target improvement. Second,
in contrast to risk-adjusted outcomes measurement, processes of care
do not need to be adjusted for differences in patient risk, which limits
the need for data collection from the medical chart and saves valuable
time and effort.
However, using processes of care has several significant limitations
in surgery. First, most existing process measures are not strongly
related to important outcomes. For example, the SCIP measures, which
are by far the most widely used process measure in surgery, are not
related to surgical mortality, infections, or thromboembolism [13].
Similarly, after implementing the preoperative checklist in 101
hospitals in Ontario, Canada, there was no measurable change in
postoperative complications or mortality [14]. The lack of a
relationship between process improvement and surgical mortality can
be explained by the fact that the complications they aim to prevent are
secondary (e.g., superficial wound infection) or extremely rare (e.g.,
pulmonary embolism). However, there is also a very weak relationship
between process measures and the outcome they are supposed to
prevent (e.g., timely administration of prophylactic antibiotics and
wound infection) [15]. This finding is more difficult to explain. It is
possible that there are simply multiple other processes (many
unmeasured or unmeasurable) that contribute to good surgical
outcomes. As a result, it is likely that adherence to process best
practices is necessary but not sufficient for good surgical outcomes.
Outcome
Outcomes represent the end results of care. In surgery, the most
commonly evaluated outcomes are mortality, serious complications,
and hospital readmissions. For example, the NSQIP, the largest clinical
registry focusing on surgery, reports risk-adjusted morbidity and
mortality rates to participating hospitals [3]. While morbidity and
mortality have long been the “gold standard” in surgery, patient-
reported outcomes such as functional status and quality of life are also
critically important.
Direct outcome measures have several strengths (Table 1.1). First,
everyone agrees that outcomes are important. Measuring the end
results of care makes intuitive sense to surgeons and other
stakeholders. For example, the NSQIP has been enthusiastically
championed by surgeons and other clinical leaders [16]. Second,
outcomes feedback alone may improve quality. This so-called
Hawthorne effect is seen whenever outcomes are measured and
reported back to providers. For example, the NSQIP in the Veterans
Affairs (VA) hospitals and private sector has documented
improvements over time that cannot be attributed to any specific
efforts to improve outcomes [17].
However, outcome measures have key limitations. First, when the
event rate is low (numerator) or the number of cases is small
(denominator), outcomes cannot be reliably measured. Small sample
size and low event rates conspire to limit the statistical power of
hospital outcomes comparisons. For most operations, surgical
mortality is too rare to be used as a reliable quality measure [18]. For
example, a study examining seven operations for which mortality was
advocated as a quality measure by the Agency for Healthcare Research
and Quality (AHRQ) found that only one of the seven operations –
coronary artery bypass surgery – had high enough caseloads to reliably
measure quality with surgical mortality [19].
Accurately measuring and comparing outcomes as a quality
improvement instrument is also confounded by many factors. Surgical
outcomes are influenced not only by quality of care but also by random
variation, sample size, and case mix. Whereas structure and process
measure are fixed elements of care, outcomes require additional risk
and reliability adjustment to account for these confounders [20].
Acquiring the data necessary to make these adjustments is labor-
intensive and expensive. For example, the NSQIP collects more than 80
patient variables from the medical chart for this purpose [17]. Each
NSQIP hospital employs a trained nurse clinician to collect this data.
Composite
Composite measures are created by combining one or more structure,
process, and outcome measures [21]. Composite measures offer several
advantages over the individual measures discussed above (Table 1.1).
By combining multiple measures, it is possible to overcome problems
with small sample size discussed above. Composite measures also
provide a “global” measure of quality. This type of measure has been
used for quality for value-based purchasing or other efforts that require
an overall or summary measure of quality.
One key limitation with composite measures is that there is no “gold
standard” approach for weighting input measures. Perhaps the most
common approach is to weight each input measure equally. For
example, in the ongoing Premier/CMS pay for performance initiative,
individual measures are weighted. However, this approach is also
flawed insofar as variation in these composite measures is entirely
driven by the process measures [22].
Another limitation with composite measures is that they are not
always actionable for quality improvement. By combining information
on multiple measures and/or clinical conditions, there is often not
enough “granularity” for clinicians to use the information for quality
improvement. To target quality improvement efforts, it is often
necessary to deconstruct the composite into its component measures
and find out where the problem lies (e.g., the specific procedure or
complication).
Patient-Reported Outcomes
An important element of surgical quality not captured in the traditional
Donabedian paradigm outlined above is patient-reported outcomes.
There is now wide recognition of the importance of patient-reported
outcomes. These outcomes capture the patient’s perspective on their
postoperative experience, and common measures include functional
status, satisfaction, and quality of life.
CMS now uses the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) survey as part of its value-based
purchasing program. Although it is still unclear how these outcomes
can be meaningfully integrated into actionable quality improvement
efforts, they are nevertheless a necessary complement to traditional
outcome measures [23]. It has been demonstrated that there is a high
association between patient satisfaction and traditional objective
outcome measures [24]. This suggests that efforts and policies to
improve the patient experience can be undertaken without negatively
impacting other important outcome measures.
Choosing the Right Measurement Approach

No approach to quality measurement is perfect. Each type of measure –
structure, process, and outcome – has its own strengths and limitations.
In general, selecting the right approach to measure quality depends on
characteristics of the procedure and the specific policy application [5].
Certain characteristics of the surgical procedure should be
considered when selecting a quality measure (Fig. 1.1). Specifically, one
should consider how risky the procedure is (i.e., how often to
complications occur?) and what the volume of the procedure is (i.e.,
how often is it performed?). For procedures that are both common and
relatively high risk (e.g., colectomy and gastric bypass), outcomes are
reliable enough to be used as measures of quality (Fig. 1.1, Quadrant I).
For procedures that are common but low risk (e.g., inguinal hernia
repair), measures of the process of care or patient-reported outcomes
are the best approach (Fig. 1.1, Quadrant II). For procedures that are
high risk but uncommon (e.g., pancreatic and esophageal resection),
structural measures such as hospital volume are likely the best
approach (Fig. 1.1, Quadrant IV). In fact, empirical data suggests that
structural measures such as hospital volume are better predictors of
future performance than direct outcome measures for these
uncommon, high-risk operations [25]. Finally, for operations that are
both uncommon and low risk (e.g., Spigelian hernia repair), it is
probably best to focus quality measurement efforts on other, more high
leverage procedures.
Figure 1.1 Choosing among measures of structure, process, and outcomes. For high-
risk, high caseload operations (e.g., colectomy and bariatric procedures), outcomes
are useful quality measures. For low-risk, common procedures (e.g., inguinal hernia
repair), processes of care or functional outcomes are appropriate measures. For high-
risk, uncommon operations (e.g., gastric and pancreatic cancer resection), measures
of structure, such as hospital volume, are most appropriate. For low-risk, low
caseload operations (e.g., spigelian hernia repair), it would be best to focus
measurement efforts elsewhere. (Figure modified by Birkmeyer et al. [5])
When choosing an approach to quality measurement, the specific
policy application should also be considered. In particular, it is
important to distinguish between policy efforts aimed at selective
referral and quality improvement. For selective referral, the main goal
is to redirect patients to the highest quality providers. Structural
measures, such as hospital volume, are particularly good for this
purpose. Hospital volume tends to be strongly related to outcomes, and
large gains in outcomes could be achieved by concentrating patients in
high-volume hospitals. In contrast, structural measures are not directly
actionable and, therefore, do not make good measures for quality
improvement. For improving quality, process and outcome measures
are better because they provide actionable targets. Surgeons and
hospitals can improve by addressing problems with process
compliance or focus on clinical areas with high rates of adverse
outcomes. For example, the NSQIP reports risk-adjusted morbidity and
mortality rates to every hospital. Surgeon champions and quality
improvement personnel will target improvement efforts to areas where
performance is statistically worse than expected.
Improving Quality Measurement

Although the science of surgical quality measurement has come a long
way in the past two decades, the methodology is still developing. Here
we outline important improvements to quality measurement that
address the problems with the process of care and outcome measures
discussed above.
A central element of meaningful outcomes reporting and
comparison is the use of appropriate risk-adjustment techniques [26].
This process helps account for variation in case mix across hospitals,
since a hospital that has a higher proportion of comorbid, complex
patients would be reasonably expected to have a higher raw number of
complications than a hospital that has younger, less sick patients. The
importance of risk adjustment is powerfully illustrated by a study
comparing outcomes after emergency colectomy between rural and
urban hospitals [27]. Before adjusting for factors such as patient age,
gender, race, and comorbidity profile, rural hospitals had a much lower
unadjusted 30-day mortality at 10.9% versus 16.3%. However, after
adjusting for this difference in patient factors, the difference narrows
substantially to 14.3% versus 16.2%, reflecting the fact that rural
hospitals tend to have less complex patients.
At present, most clinical registries collect a large number of clinical
data elements from the medical record for risk adjustment. This
“kitchen sink” approach to risk adjustment is largely based on the
assumption that each additional variable improves our ability to make
fair hospital comparisons. However, empiric data suggests that only the
most important variables contribute meaningfully to risk-adjustment
models. For example, Tu and colleagues demonstrated that a 5-variable
model provides nearly identical results to a 12-variable model for
comparing hospital outcomes with cardiac surgery [28]. Using data
from the NSQIP, we have demonstrated similar results for both general
surgical procedures [26]. These results should be used to streamline
the collection of data for risk adjustment, which will decrease the costs
of data collection and lower the bar for participation in these important
clinical registries.
Advanced statistical techniques are also needed to address the
problem of “noisy” outcome measures [29]. As discussed above,
imprecision from small sample size is the Achilles heel of outcomes
measurement. Analytic techniques that rely on empirical Bayes theory
to adjust hospital outcomes for reliability help mitigate this problem. In
this approach, the statistical “noise” is explicitly measured and removed
by shrinking the observed outcome rate back toward the average rate.
For example, Fig. 1.2 shows risk-adjusted hospital morbidity rates
across quintiles for ventral hernia repair, before and after adjusting for
reliability. Before adjusting for reliability, rates of morbidity varied
eightfold (2.3–17.5%) from the “best” to “worst” quintile. However,
after removing chance variation (i.e., “noise”) by adjusting for
reliability, rates of morbidity varied less than twofold (8.0–14.0%) from
the “best” to “worst” quintile.
Figure 1.2 Comparison of ventral hernia repair morbidity rates across hospital
quintiles (1 = “best hospitals” and 5 = “worst hospitals”) before and after adjusting
for statistical reliability. After adjusting for reliability, the apparent variation across
hospitals is greatly diminished
While this approach has many advantages, reliability adjustment
makes the assumption that small hospitals have average performance.
Although this approach gives small hospitals, the benefit of the doubt
(i.e., they are innocent until proven guilty), under certain circumstances
it could bias hospital rankings. For instance, given the well-known
relationship between volume and outcome in surgery, these small
hospitals may actually have performance below average. Incorporating
information about hospital volume could address this bias. We have
developed a novel technique for performing reliability adjustment by
shrinking to a conditional average (i.e., the outcome expected given
hospital volume) to address this problem [6]. This approach is
considered a composite measure as it includes two inputs (mortality
and volume).
This general approach can also be used to create more sophisticated
composite measures of quality. As discussed above, most current
approaches for combining measures are flawed. To address this
problem, we have developed a method for empirically weighting input
measures [30]. Briefly, we first identify a gold standard quality
measure, such as mortality or serious morbidity. We then determine the
relationship between each candidate measure and this gold standard
measure. Finally, each input measure is given a weight based on (1) the
reliability with which it is measured and (2) how correlated it is with
the gold standard measure. These empirically weighted composite
measures have been shown to be better predictors of future
performance than individual measures alone.
Measuring Surgeon, Hospital, and Network Quality

Despite continuing uncertainty about how best to methodologically
measure performance, value-based payments, surgeon report cards,
and national rankings are now a reality of surgical practice. Here we
present examples of instruments currently used to compare quality at
the surgeon, hospital, and network level and offer strategies for how
best to incorporate the above approaches into these measurements.
One example of how surgeon quality is currently measured and
presented to patients is via ProPublica’s “Surgeon Scorecard,” which
claims to report risk-adjusted individual surgeon outcomes. Currently,
the scorecard attempts to rate surgeons for eight common elective
procedures. However, recent studies have shown that this mechanism is
underpowered to detect any meaningful difference – to detect a
statistically significant difference in outcomes after laparoscopic
cholecystectomy, surgeons would need to perform at least 170 of these
cases. However, no individual surgeon in the ProPublica scorecard
comes close to that volume [31]. An emerging and likely more
meaningful approach to individual surgeon rating is the use of
intraoperative video assessment, where surgeon skill is evaluated by
peer reviewers using standardized instruments. Recent data suggest
that surgeon technical skill assessed via video review is directly related
to complication rates and mortality [32]. Quality improvement efforts
directed at individual surgeon performance are increasingly utilizing
video review [33].
Measuring quality at the hospital level requires taking into account
the multiple teams, providers, and processes that affect a patient’s
overall surgical episode. Only once we have an understanding of the
root causes that explain outcomes differences between hospitals can
best practices be promoted. One such example is the notion of “failure
to rescue,” which sheds light on the mechanisms underlying variations
in surgical mortality rates between hospitals. In a study by Ghaferi et al.
using clinically rich data from the NSQIP, hospitals were ranked
according to risk-adjusted mortality [34]. When comparing the “best”
to “worst” hospitals, they found no significant differences in overall
(24.6% vs. 26.9%) or major (18.2% vs. 16.2%) complication rates.
However, the so-called failure to rescue (death following major
complications) was almost twice as high in hospitals with very high
mortality as in those with very low mortality (21.4% vs. 12.5%, p <
0.001). This study highlights the need to focus on processes of care
related to the timely recognition and management of complications –
aimed at eliminating “failure to rescue” – to reduce variations in
surgical mortality.
Lastly, measuring the quality of hospitals networks as opposed to
individual hospitals is becoming increasingly common. Over the last
decade, hospitals have been consolidated into large multicenter
networks under the premise that this move would improve the quality
of care. Currently, the US News and World Report ranks hospitals
networks as opposed to individual hospitals to reflect this. Measuring
the quality of these networks largely relies upon traditional structure
measures such as volume. By participating in a hospital network, small
rural hospitals can refer complex surgical cases to be performed at a
high-volume center. We have already discussed that evidence is
emerging that such “volume pledge” measures may fall short [10].
Conversely, networks can also be evaluated on how well they
decentralize knowledge and best practices, so that care across the
network, regardless of hospital size, can be standardized according to
accepted guidelines [35]. Future efforts to measure surgical quality may
focus on how well guideline-concordant care is delivered across a
network of hospitals.
Conclusions
Each type of quality measure – structure, process, and outcome – has its
unique strengths and limitations. Structural measures are strongly
related to outcomes but do not discriminate among individual
providers. Process measures offer actionable steps for improvement
but often have a tenuous association with outcomes. Outcomes are the
bottom line in surgery, but sampling and adjustment methods are
needed to meaningfully compare them between hospitals and surgeons.
Other measures such as patient-reported outcomes offer critical
information, but their incorporation into quality improvement efforts is
less clear. Ultimately, when choosing among the various approaches to
define surgical quality, surgeons need to be flexible and consider the
specific policy application prior to selecting a single measure.
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
J. R. Romanelli et al. (eds.), The SAGES Manual of Quality, Outcomes and Patient Safety
https://doi.org/10.1007/978-3-030-94610-4_2
2. Never Events in Surgery

Anjali A. Gresens1, 2 and Jacob A. Tatum2
(1) Bariatric Surgery, Sentara Medical Group, Norfolk, VA, USA
(2) Department of Surgery, Eastern Virginia Medical School, Norfolk,
VA, USA
Anjali A. Gresens (Corresponding author)

Jacob A. Tatum
Keywords Never events – Medical errors – Adverse events – Serious

reportable events – Nonreimbursable events – Hospital-acquired
conditions – No pay – Wrong-site surgery
Introduction
“Never events” were first introduced in 2001 by Dr. Ken Kizer, former
CEO of the National Quality Forum (NQF) organization that promotes
patient safety and quality healthcare [1]. The term refers to medical
errors and events that are so egregious that they should be avoidable,
preventable, and never occur, such as wrong-site surgery or surgery
performed on the wrong patient [2]. Though these might seem
shocking, serious preventable surgical errors occur every year despite
considerable patient safety initiatives. Overall, medical errors are
suspected to contribute to over 251,000 deaths per year in the United
States, with an estimated 4000 surgical never events occurring yearly
[3]. Globally, Haynes et al. estimate a rate of serious incidents occurring
in 1/10,000 patients, with up to one million deaths per year [4, 5].
While an individual hospital may only see a wrong-site surgery every
5–10 years, other serious errors may occur more frequently causing
undue harm to many patients. From 2007 to 2019, 71% of never events
reported to the Joint Commission resulted in fatality [1].
Medical errors and adverse events in healthcare impose a costly toll
not only on the patient involved but also to the providers and the
institution. The burden is mental as well as financial and can be
devastating. In 2011, data from the NQF estimated that serious
reportable errors lead to $5.7 billion in additional healthcare costs.
When including healthcare expenses, lost productivity, lost income, and
disability, costs may exceed $29 billion per year in the United States [6].
Understanding What Events Are Classified by the

NQF as “Never Events” in Surgery
Never events should be preventable, and no patient should die from
these types of medical errors. In 2002, Dr. Kizer and the NQF proposed
a list of serious reportable events to increase accountability and
consumer access to critical information and healthcare performance.
The goal was to advance the delivery of safe and high-quality healthcare
through research, investigation, and collaboration. NQF aimed to
facilitate standardized reporting that was uniform across systems,
leading to systematic nationwide improvements in patient safety. To be
categorized as a “serious reportable event” (SRE) or “never event”
according to the NQF, an event must be [7]:
Unambiguous—clearly identifiable and measurable and thus feasible
to include in a reporting system
Usually preventable—recognizing that some events are not always
avoidable, given the complexity of healthcare
Serious—resulting in death or loss of a body part, disability, or more
than transient loss of a body function
Additionally, events included on the list are any of the following:
Adverse
Indicative of a problem in a healthcare facility’s safety systems
Important for public credibility or public accountability
Some of these events should absolutely never occur. Others are
largely preventable with increased education and improved prevention
programs and should trend near zero. The objective of identifying these
SREs and never events was not to penalize hospitals and programs but
to promote patient safety and advance quality improvement efforts.
Reporting is voluntary, but every healthcare organization should be in
favor of pursuing research efforts that would identify vulnerabilities.
Only by identification can issues be addressed and improved. All
organizations are held accountable by their patients, providers, staff,
and community in terms of the quality of care they provide, and every
organization should strive for the highest-quality care and patient
safety measures.
The original list of SREs has evolved into 29 serious reportable
events grouped into 7 categories:
Surgical or procedural events
Product or device events
Patient protection events
Care management events
Environmental events
Radiologic events
Criminal events
A complete list of NQF serious reportable events/never events is
found in Table 2.1 [8]. Twenty-six states and the District of Columbia
have mandated reporting of SREs [9]. Because each state has a variable
approach to reporting SREs, a nationwide effort to learn from these
events and enact change is limited.
Table 2.1 National Quality Forum serious reportable events/never events [8]
Surgical events
Surgery or other invasive procedure performed on the wrong site
Surgery or other invasive procedure performed on the wrong patient
Wrong surgical or other invasive procedure performed on a patient
Unintended retention of a foreign object in a patient after surgery or other invasive
procedure
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abgestattet haben, scheiden wir von Trier, wo so herrlicher Wein uns
labte, um auch anderen schönen Punkten im Moseltal einen
flüchtigen Wandergruß zu bringen.
Es fehlt der Raum, um das Moseltal, das so
viele herrliche Schönheiten entfaltet, in gleicher Das Moseltal.
Ausführlichkeit wie das Rheintal zu behandeln. Wir
müssen uns darauf beschränken, die Eigenart dieses größten
Nebentales gegenüber dem Haupt-, dem Rheintale, zu zeigen und
zu begründen. Übereinstimmend ist der reiche Rebenschmuck der
Bergwände, die ebenfalls aus schiefrigem Gestein bestehen; gleich
ist auch die große Zahl der Burgen, die malerisch die Berge krönen;
sehr ähnlich ferner das Bild der Ortschaften, die an den Fluß sich
betten, und deren schiefergraue Dächer im Sonnenschein hell
aufblitzen. Und doch wie verschieden ist das Gesamtbild! Weniger
großartig ist das Moseltal, wie auch sein Fluß sich mit dem stolzen
Rheinstrom nicht messen kann. Aber ein reicherer Wechsel des
landschaftlichen Bildes ist ihm eigen. Schon die viel zahlreicheren
Biegungen, die die Mosel macht, bewirken dies; denn bei jeder
Biegung öffnet sich dem Auge ein neues, oft völlig anderes Bild,
während sich im Rheintal jeder Blick ins Endlose verlängert. Am
wenigsten ist die unterste Strecke des rheinischen Mosellaufs, von
Cochem ab, durch Biegungen gegliedert, am reichsten das mittlere
Drittel zwischen Bernkastel und Cochem. Dort macht der Fluß
vielstundenlange Umwege, um fast zur nämlichen Stelle
zurückzukehren. Am meisten nähert er sich selbst wieder nach der
großen Schleife von Zell an der Stelle, wo die auf hohem Felskamm
gelegene Marienburg (Abb. 100) zur Betrachtung des eigenartigen
Landschaftsbildes mit einem doppelten Flußlaufe einladet.
Abb. 114. Die Apollinariskirche in Remagen. (Zu Seite 117.)
Wir verlassen in Bullay das Moselschiff und

steigen auf steilem Pfad zwischen Weinbergen Die Marienburg.
hinan. Rückwärts schauend, erblicken wir tief unter Von Bernkastel
bis Cochem.
uns den Fluß, der sich in Schlangenbiegungen
hinter den Bergen verliert, und grüßen das Schifflein, das langsam
die Welle durchfurcht. Bald haben wir die Gebäude der Marienburg
(Abb. 101) erreicht. Es sind die Ruinen eines sagenhaften
Schlosses, an dessen Stelle 1146 ein Frauenkloster gegründet
wurde. Das malerische Chor der damals erbauten Kirche ist noch
ziemlich gut erhalten. Wir wandeln zwischen den Trümmern und
durchschreiten den in Gartenanlagen umgewandelten Burg- oder
Klosterhof. Auf der andern Seite der Marienburg bleiben wir
überrascht stehen. Auch dort zu unsern Füßen ein großer Flußlauf,
die Mosel!
„Oftmals bewunderst du selbst im Stromlauf die eigene
Rückkehr“
so sang schon der römische Dichter Ausonius, der auch die

Mosel und den Hunsrück bereiste. Im Burggarten lassen wir uns
nieder und erquicken uns am kühlen Wein. So sitzen wir lange. Aber
immer wieder lockt es uns, hinauszutreten und die herrliche
Landschaft, das Doppelbild, auf der einen Seite das Bild der
Eifelhöhen, auf der andern das der Hunsrückberge, zu betrachten,
bis das Schifflein kommt, das wir vorher verließen. Dann springen
wir hurtig hinunter und setzen in Pünderich die Fahrt fort.
Abb. 115. Altenahr. (Zu Seite 118.)
Daß auch in wirtschaftlicher Hinsicht das Moseltal durch die

großen Biegungen mehr gegliedert wird, erkennen wir an dem
Aufblühen zahlreicher Städtchen und Flecken, z. B. von Bernkastel
(4500 Einw.) (Abb. 102), Traben-Trarbach (5500 Einw.) (Abb. 103),
Zell (Abb. 106) und Cochem (Abb. 105), die sämtlich auf der
mittleren Moselstrecke liegen, während zwischen Cochem bis
Coblenz kaum noch ein Ort von der Bedeutung dieser Städtchen
folgt. Auch die obere Strecke, zwischen Trier und Bernkastel, kann
sich in dieser Hinsicht nicht mit der mittleren messen. In früherer Zeit
hatte dort die Mosel einen andern Lauf. Sie folgte in mehr gerader
Richtung einer Senke, die nördlich von dem jetzigen Lauf auch heute
noch ausgeprägt ist und als ein ziemlich ebenes Gelände einen Teil
der Ansiedelungen an sich zog. Auf dem mittleren Laufdrittel bildeten
sich die genannten Städtchen zu natürlichen Mittelpunkten der durch
die Talbiegungen voneinander ziemlich abgeschlossenen
Landschaften aus. Diese erweitern sich meist noch durch ein kleines
Seitental, auf dessen unterste Strecke die nämliche
Wirtschaftsweise, vor allem der Weinbau, übertragen werden
konnte.
Abb. 116. Neuenahr, von der Thomashöhe gesehen.

Nach einer Photographie von Stengel & Co. in Berlin. (Zu Seite 120.)
Die zahlreichen Biegungen der Mosel hatten Mosellandschaft

ferner zur Folge, daß, bei der Hauptrichtung des und -orte.
Flusses nach Nordosten, stets nur die wechselnde
Talseite mit Reben bepflanzt werden konnte. Auf der andern, mit
ihren Abhängen mehr nach Norden gerichteten — bald ist’s die linke,
bald die rechte — blieb der Wald bestehen. Meistens sind es
Lohhecken, die diese bekleiden. So entsteht ein Wechsel der
Belaubung. Auf die kahlen und in sehr gleichmäßigem Grün
erscheinenden Weinberge folgen wechselvoller beleuchtete und
gefärbte Waldpartien, auf diese wieder Weinberge und so fort:
entschieden ein landschaftlicher Vorzug gegenüber dem Rheintal,
wo auf weiten Strecken die Rebenanlagen bis zur Ermüdung im
Landschaftsbilde immer wiederkehren. Die stärkere Bewaldung hat
auch zur Folge, daß die Moselberge gerundeter erscheinen als die
Berge des Rheintales, dessen schroffe Formen durch die Weinberge
nur wenig gemildert werden.
Abb. 117. Der Rolandsbogen mit Blick auf den Drachenfels. (Zu Seite 123.)
Unter den Moselorten sind manche, die auf ein hohes Alter
zurückschauen können, wie Pfalzel (von Palatiolum), wo Adela, die
Tochter des Frankenkönigs Dagobert II., ein Frauenkloster gründete;
Riol (von Rigodulum), wo nach dem Bericht des Tacitus der römische
Feldherr Cerealis die Treverer besiegte; Neumagen (von
Noviomagus), wo in der Nähe der Kirche eine Festung Constantins
lag, die der Dichter Ausonius erwähnt:
„Drauf sah ich an des Belgerlandes Grenzen

Die Prachtburg Constantins Neumagen glänzen.“
Enkirch, schon 690 als Villa Ancaracha genannt;

Cochem (Cuchuma), das im zehnten Jahrhundert als Burg Cochem.
Reichslehn des Aachener Pfalzgrafen erwähnt
wird; Treis (Trisvilla); Carden (Caradona) (Abb. 104), wo im vierten
Jahrhundert der heilige Kastor in einer Höhle gelebt haben soll u. a.
Von den zahlreichen Burgen seien als die schönsten oder in Sage
und Geschichte am meisten genannten außer der Marienburg noch
erwähnt die Burgen von Cobern, Burg Thurant bei Alken, die in
einem engen Seitental gelegene Ehrenburg (Abb. 107), die
Reichsburg Beilstein (Abb. 108), die Festung Montroyal auf dem
Trabener Berg, deren Schleifung 1697 durch den Ryswycker Frieden
verfügt wurde, und vor allem die turmreiche, in neuer Schönheit
wieder hergestellte Burg Cochem (Abb. 109). Letztere gehörte von
866 bis 1140 den Pfalzgrafen bei Rhein und war bis 1294
Reichsburg. Die Franzosen zerstörten den herrlichen Bau im Jahre
1689. Lange lag sie in Trümmern, bis der Geheime Kommerzienrat
Ravené sie nach alten Plänen und Ansichten 1868 bis 1878 neu
aufführen ließ und dadurch dem Moseltal seinen hervorragendsten
Schmuck wiedergab. Andere Moselorte sind noch als Weinorte
berühmt geworden, wie Graach, Erden, Zeltingen (Abb. 110), Lieser,
Winningen usw. In einem Seitental der Mosel liegt inmitten einer
herrlichen Waldespracht das Bad Bertrich (Abb. 111).
Abb. 118. Schloß Drachenburg und Zahnradbahn nach dem Drachenfels.
VI. Das Rheintal von Coblenz bis
Bonn.
Wieder ladet ein stattlicher Dampfer, die
„Hansa“, zur Rheinfahrt uns ein, zur Fahrt von Das Neuwieder
Coblenz nach Bonn, der rheinischen Musenstadt. Becken.
An dem Denkmal Wilhelms des Großen gleiten wir vorüber, und der
Stadt Coblenz, ihrer ehrwürdigen Kastorkirche, dem hochragenden
Kühkopf und dem trotzigen Ehrenbreitstein senden wir die letzten
Grüße zu. Die freie Ebene säumt nun auf der linken Seite den
Strand des stolzen Stromes. Etwa eine Stunde weit treten die Höhen
zurück, um in dieser Entfernung nordwärts den Strom zu begleiten.
Rechts aber bleiben sie ihm noch eine Strecke weit so nahe, daß sie
sich in seinen Fluten spiegeln können. Eine grüne Rheininsel,
Niederwerth mit dem gleichnamigen Örtchen, verdeckt den Blick
nach Osten, wo sich das Städtchen Vallendar an den Strom
schmiegt. An ihrem Nordende weichen auch die Höhen auf der
rechten Rheinseite zurück, und weicher Strand begleitet auf beiden
Seiten den zu größerer Breite anschwellenden Strom. Wir blicken
frei über die inmitten des Rheinischen Schiefergebirges
eingebrochene Scholle des Neuwieder Beckens. Nordwärts aber
nähern sich wieder die beiderseitigen Höhen, um von neuem den
Rhein zu umklammern.
Abb. 119. Brückenbogen über den Rhein bei Bonn.
Die qualmenden Hochöfen der Kruppschen Concordiahütte

ziehen in der rechtsseitigen Ebene unsern Blick auf sich, und an das
rechte Stromufer drängt sich der Ort Engers, dessen früheres, 1758
erbautes kurtrierische Schloß seit 1863 als Kriegsschule dient. Links
aber wird das Dorf Urmitz sichtbar, ein den Archäologen
wohlbekannter Ort, mit dem sie sich in jüngster Zeit wieder in
erhöhtem Maße beschäftigt haben.
Abb. 120. Zollhäuschen auf der Bonner Rheinbrücke.
Aus der Festschrift der Stadt Bonn. (Zu Seite 125.)
Es handelt sich wieder um die Frage, wo
Cäsar seine beiden Brücken über den Rhein Wo waren Cäsars
geschlagen hat. Es ist eine alte Kampffrage. Nicht Rheinbrücken?
Urmitz.
weniger als etwa zwanzig Orte haben sich auf der
320 km langen Rheinstrecke von Mainz bis Xanten, wie Nissen
schreibt, zur Auswahl angeboten. „In Engers überschaut der Fremde
vom Römerturm die lachende Landschaft und hält im Gasthof zur
Römerbrücke Rast, in Bonn freut er sich der Huldigung, die 1898
dem ersten rheinischen Brückenbauer zuteil geworden ist, sieht ein
Steinbild, das den großen Imperator darstellen soll, liest eine
Inschrift, die in bedenklichem Latein das Gedächtnis des
Brückenschlages von 55 v. Chr. erneuert.“ Der um die
Altertumsforschung im Rheinland hochverdiente Oberst von
Cohausen verlegte die erste Brücke, die im Jahre 55 v. Chr.
geschlagen wurde, nach Xanten, die zweite, zwei Jahre später
erbaute nach Neuwied, indem er in der Stelle paulum supra eum locum
quo ante exercitum traduxerat, facere pontem instituit“ in Cäsars „Bellum
gallicum“ den beiden ersten Worten „ein wenig oberhalb“, nämlich von
der Stelle des ersten Brückenbaues, einen sehr dehnbaren Sinn
gab. In dem großen Werke Napoleons III. über die Feldzüge Cäsars
ist Bonn als Brückenstelle angenommen worden, und hierauf
gründet sich die Ehrung des römischen Feldherrn an der Bonner
Rheinbrücke. Andere, wie General von Peucker und General Wolf,
traten für Köln ein, wieder andere, wie Professor Ritter 1864 und
Professor Klein 1888, nahmen die erste Brücke für Bonn, die zweite
für Neuwied in Anspruch. In neuester Zeit glaubt nun Koenen, der
unermüdliche Durchforscher unseres Heimatbodens nach Spuren
der Vergangenheit, wenig unterhalb von Urmitz und dem Urmitzer
Wörth Cäsars Rheinfestung ermittelt und in ihrer Ausdehnung und
Anlage genau festgestellt zu haben. Es handelt sich um eine
Festungsanlage von fast 4 km Umfang, die auf einer erhöhten, von
den Fluten nicht erreichbaren Bimssandsteinablagerung errichtet
war. In dem Rahmen derselben waren früher schon viele römische
und vorrömische Funde gemacht, u. a. zahlreiche Kesselgruben der
Bronze-, Hallstatt- und La Tène-Zeit, sowie ein großes vorrömisches
Gräberfeld, das Totenwohnungen besonders aus jenen Perioden
barg, entdeckt worden. Es handelt sich also um eine im früheren
Völkerleben wichtige Örtlichkeit. Innerhalb der großen
Festungsanlage hat Koenen ferner eins der fünfzig Drusus-Kastelle
von quadratförmiger Gestalt nachgewiesen. Welche Gründe
berechtigten ihn aber, jene als die Cäsarsche Brückenfestung zu
deuten? In dem Füllwerk der Festungsgräben fanden sich
Gefäßscherben aus allen Perioden der vorrömischen Zeit, keine
aber, die bis in die Augusteische Zeit hineinreichen. Die jüngsten
Scherben zeigen den Typus, der in der Zeit der Eroberung Galliens
durch Cäsar herrschte. Im Rheine wurden gegenüber der Mitte des
Lagers Reste von Pfählen gefunden, desgleichen etwas (1270 m)
unterhalb, wohin Koenen den Bau der ersten Brücke verlegt. Die
Cäsarsche Brückenfestung hat, nach der Beweisführung Koenens,
bis nach dem unter Augustus erfolgten Bau der Coblenzer Straße
bestanden; denn diese biegt, wo sie jene erreicht, nach Westen aus.
Nach völliger Beruhigung des linken Rheinufers war eine große
Rheinfestung nicht mehr nötig. Das kleine Drusus-Kastell übernahm
an dieser Stelle die Sicherung der Rheingrenze, und jene wurde
aufgegeben. Die Entscheidung der Frage, wo Cäsar über den Rhein
gegangen ist, hat große Wichtigkeit für die Feststellung der alten
Grenzen der germanischen Völkerschaften, in deren Gebiet der
Kriegszug führte. Ob aber Koenens Forschungen dem Streit ein
Ende machen werden, ist noch nicht gewiß. Allgemein scheint man
sich aber jetzt der Ansicht anzuschließen, daß jedenfalls in der
Gegend des Neuwieder Beckens, also zwischen Coblenz und
Andernach, die Stellen zu suchen sind, wo Cäsar den Rhein
überschritt.
Der Rheindampfer trägt uns an der interessanten Örtlichkeit, um
die sich jetzt der wissenschaftliche Streit dreht, vorbei. Wir sehen im
Geiste die Cäsarsche Pfahlbrücke, die uns auf der Schulbank schon
so viel Kopfzerbrechen machte. Wo einst römische Legionen
lagerten, sind jetzt zahlreiche Arbeiter tätig im Dienste einer
eigenartigen Industrie. Sie stechen den Bimssand, den einst die
Vulkane der Eifel als Aschenregen entsandten, ab, untermischten
ihn mit Kalkmilch und formen aus der Masse weiße
Bimssandsteinziegel, die bei Bauten im Rheinland jetzt viel
Verwendung finden. Die Steine sind viel leichter als die
gewöhnlichen Ziegelsteine und sollen den Gebäuden eine
gleichmäßige Temperatur geben. Durch den Abbau der
Bimssandsteinschichten für die zahlreichen Ziegeleien, die zwischen
Coblenz und Andernach, sowie auch auf der rechten Rheinseite in
Betrieb gesetzt wurden, und die jährlich über hundert Millionen
Ziegel fertig stellen, sind schon viele wertvolle, besonders
vorgeschichtliche Funde gemacht worden — den Namen Urmitz
können wir in den meisten Museen lesen —, und auch Koenen
verdankt ihnen die Entdeckung der Cäsarschen Rheinfestung und
des Drusus-Kastells.
Am linken Rheinufer folgt der langgestreckte
Ort Weißenturm, hinter dem sich, seitwärts von der Weißenturm.
Landstraße, auf einer Anhöhe das Denkmal des Neuwied.
französischen Generals Hoche in Gestalt eines Obelisken erhebt.
Rechts aber wird, unterhalb zweier Kruppscher Hüttenwerke, das
Stadtbild von Neuwied (fast 20000 Einwohner) sichtbar. Schon der
Name deutet das junge Alter der betriebsamen Stadt an. Einst lag an
ihrer Stelle ein Ort namens Langendorf. Im Dreißigjährigen Kriege
war er völlig verödet. Da lud 1653 der Graf Friedrich von Wied
zahlreiche Ansiedler „ohne vnterschied der Religion und ohne
einigen Pfenning zu zahlen“ zur Ansiedelung an dieser Stelle, die,
inmitten einer fruchtbaren Ebene, am Ufer des Rheinstromes und
am Ausgange des Wiedtales, als eine günstige gut erspäht war. Und
ein blühendes Gemeinwesen ist dort entstanden, in dem
Protestanten, Katholiken, Herrnhuter, Mennoniten und Juden, im
Sinne des Gründers, friedlich nebeneinander wohnen. Auch in der
Gegend von Neuwied sind, bei dem Orte Niederbiber, die Reste
eines römischen Kastells, und zwar eines der größten am Rhein,
aufgedeckt worden. Es maß 255 m in der Länge und 187 m in der
Breite. Kein römischer Schriftsteller nennt den Namen dieses
Kastells. Bei den Ausgrabungen wurden manche wertvolle Funde
gemacht, die in einem Nebengebäude des fürstlichen Schlosses zu
Neuwied aufbewahrt werden. Als das wertvollste Fundstück wird uns
ein silbernes Kohortenzeichen gezeigt. Von Neuwied, seinem Schloß
und dem schönen Parke, der dieses umgibt, können wir nicht
Abschied nehmen, ohne der gottbegnadeten Dichterin Carmen
Sylva, der Königin von Rumänien, zu gedenken, die dort geboren ist
und von dort die schönen Rheinbilder schaute, die so manche
poetische Stimmung weckte.
Abb. 121. Rheinischer Humor in den Bildhauerarbeiten der Bonner Rheinbrücke.

Aus der Festschrift der Stadt Bonn. (Zu Seite 125.)
Unterhalb der Stadt Neuwied strömen dem Andernach.

Rhein zwei starke Bäche zu, von links die muntere
Nette, von rechts die Wied. Aber kaum hat er diese, noch im ruhigen
Laufe durch die Ebene, aufgenommen, da nähern sich wieder die
Berge, um von neuem in ein felsiges Bett ihn zu zwingen. Auf der
letzten Uferfläche, die die Berge noch frei ließen, erwuchs die alte
Stadt Andernach (8000 Einwohner) (Abb. 112). Vielleicht befand sich
schon eine keltische Ansiedelung daselbst. Die Römer hatten mit
scharfem Blick den wichtigen Punkt am Eingange des zweiten engen
Abschnittes des Rheintales erspäht und legten eins der fünfzig
Drusus-Kastelle dort an, das sie Antunnacum, Antonaco nannten. Dann
ward Andernach ein fränkischer Königshof und im Mittelalter freie
Reichsstadt, bis es, durch Gewalt gezwungen, dem Erzbistum Köln
einverleibt wurde. Und von Kriegeswehr spricht auch das heutige
Bild der Stadt noch zu uns. Schon von weitem grüßt uns der hohe,
unten runde, oben achteckige Wartturm, der von 1451 bis 1468
erbaut wurde und 1880 in seiner schönen Form wiederhergestellt
worden ist. Näher kommend, erblicken wir aber noch viele Gebäude,
die das Mittelalter übrig gelassen hat: die alte Bastei, das Rheintor,
die Trümmer des kurkölnischen Schlosses und am unteren Ende,
einsam am Rheinufer stehend, den alten Kranen, die Stelle
bezeichnend, wo schon die Römer die bei Niedermendig
gebrochenen Mühlsteine verluden, und wo auch heute die im weiten
Umkreise gewonnenen vulkanischen Produkte zur Verladung
gelangen. Mauern umgeben noch den größten Teil der Stadt. In dem
altertümlichen Rathause, einem spätgotischen Bau aus dem Jahre
1564, werden römische und fränkische Altertümer aufbewahrt. Den
schönsten Schmuck Andernachs aber bildet die der heiligen
Genoveva geweihte, viertürmige Pfarrkirche. Sie ist ein
spätromanischer Bau aus dem Jahre 1206. Das mit einer
Säulchengalerie geschmückte Chor ist jedoch etwas älter und
stammt schon aus dem Jahre 1120. Wie der Besucher Andernachs
von den altertümlichen Gebäuden der eng gebauten Stadt gefesselt
wird, so kehrt er befriedigt auch von dem nördlich, am Eingang des
Rheintales aufsteigenden Kranenberg, auf den seit einigen Jahren
eine Zahnradbahn führt, zurück. Zu seinen Füßen lag das
eigenartige Stadtbild von Andernach; weit schweifte der Blick über
die fruchtbaren Gefilde des Neuwieder Beckens; in der Ferne winkte
Coblenz, durch das Silberband des Rheinstroms mit der Nähe
verbunden, und nordwärts konnte er diesen in seinem engen Tal,
das sich am späten Nachmittage allmählich in eine dunkle Schlucht
verwandelt, bis Remagen hin verfolgen.
Abb. 122. Das Bröckemännche der Bonner Rheinbrücke. (Zu Seite 125.)
Die Rheintalstrecke von Andernach bis Bonn
kann sich an Schönheit mit der Strecke von Bingen Hammerstein.
bis Coblenz nicht messen; nur für den letzten Rheineck.
Abschnitt, in dem die Sieben Berge vor uns auftauchen, gilt dieses
Urteil nicht. Aber der landschaftlichen Reize bleiben noch genug, um
eine genußreiche Stromfahrt zu bereiten. Trotzig ragt auf der rechten
Rheinseite der gewaltige Grauwackenfels vor uns auf, der einst die
stolze Burg Hammerstein trug, in der Kaiser Heinrich IV. auf der
Flucht vor seinem Sohne Heinrich V. sich im Jahre 1105 eine
Zeitlang aufhielt. Im Dreißigjährigen Kriege hausten abwechselnd
Schweden, Spanier, Kurkölner und Lothringer in derselben. Schon
1660 wurde sie auf Veranlassung des Erzbischofs von Köln zerstört,
und zwar recht gründlich; denn nur noch geringe Trümmerreste
bedecken die Bergeskuppe. Günstiger war das Schicksal der Burg
Rheineck, die uns von der linken Talwand grüßt, sobald das Schiff
an den beiden freundlichen Rheinorten Brohl und Rheinbrohl, von
denen jener links, dieser rechts das Ufer säumt, vorübergleitet. Zwar
wurde sie zweimal, 1689 von den Franzosen und 1692 von
kurkölnischen Truppen zerstört. Aber der stattliche, 20 m hohe
Bergfried hielt trotzig stand und blickt noch heute stolz in die Fluten
des Rheines hinab. Längst, seit 1548, ist das Geschlecht von
Rheineck ausgestorben. Ein Herr von Bethmann-Hollweg ließ jedoch
1832, unter dem Schirm des alten Bergfrieds, einen neuen Bau
aufführen und diesen im Innern durch Steinle mit Fresken
schmücken. Auch schräg gegenüber auf einem Bergabhange der
rechten Rheinseite, über dem Orte Hönningen, der durch seinen
Hubertussprudel und den in der Nähe erbohrten Arienheller Sprudel
bekannt geworden ist, erwuchs in neuer Pracht ein stolzer Bau,
Schloß Arenfels oder Argenfels. Sein erster Erbauer, Heinrich von
Ilsenburg, benannte es nach seiner Gemahlin, einer Gräfin von Are.
1849 kam es in den Besitz des Grafen Westerholt, der es durch
keinen geringeren als den berühmten Kölner Dombaumeister Ernst
Friedrich Zwirner prächtig erneuern ließ.
Indem wir unsern Blick auf die beiden
Schlösser richteten, bemerkten wir kaum, welche Goldene Meile.
große Veränderung mit dem Rheintale vor sich
ging. Aus der engen Felsenspalte, die bei Andernach sich schloß,
bei Rheinbrohl aber wieder öffnete, hat der Strom sich glücklich
herausgewunden. Nun kann er wieder zwischen weichen Strand sich
betten, nun lachen ihm wieder grüne Wiesen, mit Obstbäumen
besetzte Fluren. Eine kleinere Ebene hat sich zwischen Rheinbrohl
und Hönningen auf der rechten Rheinseite gelagert, eine größere
zwischen Niederbreisig, das Hönningen gegenüber liegt, und
Remagen auf der linken Seite. Jene ist etwa 1 km, diese 2 bis 3 km
breit. Die schnellfüßige Ahr, die infolge ihres eiligen Laufes viel
Schlamm und Gerölle mit sich führt, hat die größere Ebene
abgelagert. Durch ihre Anschwemmungen wurde der Rhein immer
mehr nach Osten gedrängt. Indem er aber diese Biegung machte,
wurde er veranlaßt, das rechte, felsige Ufer anzunagen, am linken,
dem toten Ufer dagegen seine Schwemmstoffe abzulagern. So
halfen Ahr und Rhein gemeinsam, die schöne fruchtbare Ebene an
der Ahrmündung, die Goldene Meile genannt, aufzubauen, über die
mit Wonne unser Blick hinüber nach den beiden Städtchen Sinzig
(über 3000 Einw.) und Remagen (3800 Einw.) (Abb. 113) schweift.
Am rechten Ufer aber grüßt uns das alte Städtchen Linz (3600
Einw.).
Abb. 123. Arndt-Denkmal in Bonn. (Zu Seite 126.)

The SAGES Manual of Quality Outcomes and Patient Safety 2nd Edition John R Romanelli Jonathan M Dort Rebecca B Kowalski Prashant Sinha

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The SAGES Manual of Quality Outcomes and Patient Safety 2nd Edition John R Romanelli Jonathan M Dort Rebecca B Kowalski Prashant Sinha

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The SAGES Manual of Quality

Outcomes and Patient Safety 2nd

Nursing Leadership and Management for Patient Safety

Total manufacturing assurance : controlling product

The SAGES Manual Operating Through the Endoscope 2nd

Using Patient Reported Outcomes to Improve Health Care

Handbook of Patient Safety Peter Lachman (Editor)

Measuring the Impact of Interprofessional Education on

LEARNING ANALYTICS : using talent data to improve

Vaccine Safety Manual 2nd Edition Neil Z. Miller

The SAGES Manual of Quality, Outcomes

ISBN 978-3-030-94609-8 e-ISBN 978-3-030-94610-4

The use of general descriptive names, registered names, trademarks,

This Springer imprint is published by the registered company Springer

Manoj Kumar Choudhury

Gretchen Purcell Jackson

Rocco Orlando III

Julio Santiago Perez

William C. Sherrill III

1. Defining Quality in Surgery

Type of Example Advantages Disadvantages

Choosing the Right Measurement Approach

Improving Quality Measurement

Measuring Surgeon, Hospital, and Network Quality

2. Never Events in Surgery

Anjali A. Gresens (Corresponding author)

Keywords Never events – Medical errors – Adverse events – Serious

Understanding What Events Are Classified by the

Wir verlassen in Bullay das Moselschiff und

so sang schon der römische Dichter Ausonius, der auch die

Abb. 115. Altenahr. (Zu Seite 118.)

Daß auch in wirtschaftlicher Hinsicht das Moseltal durch die

Abb. 116. Neuenahr, von der Thomashöhe gesehen.

Die zahlreichen Biegungen der Mosel hatten Mosellandschaft

„Drauf sah ich an des Belgerlandes Grenzen

Enkirch, schon 690 als Villa Ancaracha genannt;

Die qualmenden Hochöfen der Kruppschen Concordiahütte

Abb. 121. Rheinischer Humor in den Bildhauerarbeiten der Bonner Rheinbrücke.

Unterhalb der Stadt Neuwied strömen dem Andernach.

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