Critical access hospitals are located in rural areas, at least 35 miles from any other hospital. Prior studies found these hospitals may have worse outcomes for patients with acute myocardial infarction, congestive heart failure, or pneumonia, compared with other acute care hospitals. Using data from the Healthcare Cost and Utilization Project and American Hospital Association, this study examined surgical outcomes from 136 nonfederal general hospitals with fewer than 50 beds. Following adjustments for patient mix, hospital characteristics, and number of discharges, investigators found no differences in surgical patient safety indicators between critical access rural hospitals and comparably sized prospective payment hospitals. This finding demonstrates the importance of quality surgical care in rural hospitals. An AHRQ-funded toolkit provides resources for small rural hospitals interested in implementing safety measures.