Concomitant with the development of guidelines for the use of prophylactic antibiotics in surgery, the Veterans Administration undertook a survey of its surgical chiefs in which the likelihood of peer review guidelines being an effective method of quality assurance was assessed. The scope of the present problem was also assessed in terms of the misuse of antimicrobial agents in surgical units. The implications of this study for quality assurance are: (1) Chiefs of surgery can be influenced by peer review guidelines, but other sources can also have impact. (2) The control practices used by chiefs to influence their staffs are limited. (3) The mechanisms used by chiefs to monitor adherence to their policies are mostly informal. The implications of this study in relation to surgical antibiotic prophylaxis are: (1) The practices of surgical chiefs differ significantly from peer review guidelines. (2) The problem is far more serious for certain surgical procedures than for others. (3) Most misuse errors are errors of commission rather than omission.
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