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Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients

Educational Objective To identify to what extent reports of unprofessional behavior are associated with postoperative complications.
1 Credit CME
Key Points

Question  Do patients of surgeons with a higher number of coworker reports about unprofessional behavior experience a higher rate of postoperative complications than patients whose surgeons have no such reports?

Findings  Among 13 653 patients in this cohort study undergoing surgery performed by 202 surgeons, patients whose surgeons had a higher number of coworker reports had a significantly increased risk of surgical and medical complications.

Meaning  Surgeons who model unprofessional behaviors may help to undermine a culture of safety, threaten teamwork, and thereby increase risk for medical errors and surgical complications.

Abstract

Importance  For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.

Objective  To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports.

Design, Setting, and Participants  This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019.

Exposures  Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation.

Main Outcomes and Measures  Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation.

Results  Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; ≥4 reports, 294 of 2087 [14.1%]; P < .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; ≥4 reports, 159 of 2087 [7.6%]; P < .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; ≥4 reports, 196 of 2087 [9.4%]; P < .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05).

Conclusions and Relevance  Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients’ risk for adverse outcomes.

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Article Information

Accepted for Publication: April 15, 2019.

Corresponding Author: William O. Cooper, MD, MPH, Center for Patient and Professional Advocacy, Vanderbilt University School of Medicine, 2135 Blakemore Ave, Nashville, TN 37212 (william.cooper@vumc.org).

Published Online: June 19, 2019. doi:10.1001/jamasurg.2019.1738

Author Contributions: Dr Cooper and Mr Domenico had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cooper, Spain, Guillamondegui, Kelz, Hopkins, Catron, Dmochowski, Hickson.

Acquisition, analysis, or interpretation of data: Cooper, Spain, Guillamondegui, Domenico, Hopkins, Sullivan, Moore, Pichert, Webb, Dmochowski.

Drafting of the manuscript: Cooper, Guillamondegui, Domenico, Dmochowski, Hickson.

Critical revision of the manuscript for important intellectual content: Cooper, Spain, Guillamondegui, Kelz, Domenico, Hopkins, Sullivan, Moore, Pichert, Catron, Webb, Hickson.

Statistical analysis: Cooper, Domenico.

Administrative, technical, or material support: Cooper, Spain, Guillamondegui, Sullivan, Moore, Pichert, Catron, Dmochowski, Hickson.

Supervision: Cooper, Spain.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Vanderbilt Center for Patient and Professional Advocacy.

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the NSQIP teams at Vanderbilt Medical Center, Nashville, Tennessee, and Stanford University, Stanford, California. Judith A. Dudley, BS, Vanderbilt University Medical Center, performed data set linkages; Barbara Martin, MBA, RN, Vanderbilt University Medical Center, facilitated NSQIP data downloads and variable definitions; Shannon Stratton, BS, Vanderbilt University Medical Center, served as research coordinator. None of the contributors were compensated beyond their salaries.

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