• Johan Paulander, Rebecca Ahlstrand, Erzsébet Bartha, Lena Nilsson, Klara Rakosi, Gabriel Sandblom, Egidijus Semenas, and Sigridur Kalman.
• Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
• Acta Anaesthesiol Scand. 2024 Oct 1.

BackgroundPostoperative mortality might be influenced by postoperative care, vigilance, and competence to rescue. This study aims to describe the course of events preceding death in a high-risk surgical cohort.MethodsWe analyzed hospital records of patients who died within 30 days after surgery in 4 high volume hospitals using (1) reflective narrative thematic approach to identify recurring themes reflecting issues with conduct of care and (2) Global Trigger Tool to describe incidence, timing, and types of adverse events (AEs) leading to harm.ResultsPreoperative predicted median risk of death in the studied group was 9%/13% according to SORT/P-POSSUM, respectively. Nine recurring themes were identified. Prominent themes were "consensus concerning aim and/or risk with planned surgery," "level of (intraoperative) competence and monitoring," and in the postoperative period "level of care and vigilance" on signs of deterioration. We found a total of 303 AEs, with only three patients (5%) having no adverse events. Most common severity category was "I," that is "contributed to patient's death" (n = 110, 36% of all AEs). Of these, 60% were classified as preventable or probably preventable. The peak incidence of AEs was seen on the day of index surgery. Most common types of AEs were "failure of vital functions" (n = 79, 26%), followed by infections (n = 45, 15%).ConclusionsA high predicted risk of death and a peak of adverse events on the day of index surgery were detected. Identified themes reflect lack of documented multi-professional consensus on how to handle prevalent perioperative risk, vigilance, and postoperative level of care.© 2024 Acta Anaesthesiologica Scandinavica Foundation.

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