Adverse events continue to harm surgical patients. Studies suggest that up to 50% of hospital adverse events occur among surgical patients.1 The incidence of adverse events in free-standing ambulatory surgery centers is unknown, since patients experiencing harms are typically not treated at the facilities where their surgeries were performed.
Nontechnical skill deficits (in leadership, communication, team work, and situational awareness) occur with discouraging frequency in surgery. These lapses inhibit communication and make the patient more vulnerable to harm from technical errors.2 The complexity of modern surgery and the technology that supports it is predisposed to the “emergence” of patient harms in nonlinear, unpredictable ways.