While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.

This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."

… staffing on nights and weekends has been associated with a greater risk of adverse outcomes. However, this study found …

… practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued …

… adverse event experienced negative emotions, and only a minority accessed formal support systems . This work …

Intraoperative adverse events have been shown to increase the risk of hospital readmission. In this study, investigators found that intraoperative adverse events during abdominal surgery were associated with increased postoperative mortality, morbidity, and length of stay.

… with major intraoperative adverse events experienced a two-fold increase in readmission rates. …

The Patient Safety Indicators (PSIs) had only moderate predictive accuracy for identifying adverse events compared with independent clinical review. As shown in prior research, many errors identified by the PSIs were actually present on admission.

This study examined the predictive value of three AHRQ Patient Safety Indicators intended to detect postoperative adverse events and found that these indicators were not accurate enough to be used as quality measures.