title: Clinical events reported by surgeons assessing their peers.
abstract: BACKGROUND
  All surgical deaths in Queensland, Australia are reviewed by external surgeon peers, and clinical events are recorded. The study objective was to classify clinical events in surgical patients who died.
  
  
  METHODS
  Deaths notified to the Queensland Audit of Surgical Mortality between 2007 and 2013 were assessed by surgeons' peers who decided whether a clinical event occurred. The most serious clinical event per patient was analyzed.
  
  
  RESULTS
  Peer surgeons reviewed 4,816 deaths. Most patients (70.7%) had no clinical event. Events were preventable in 58% of patients and less than 1 in 10 events was severe. The most frequent events were classified as patient assessment (34.5%), suboptimal therapy (15.3%), and delays (15.1%).
  
  
  CONCLUSIONS
  Peer review of all surgical deaths identifies preventable clinical events and provides opportunities to improve decision making, better therapy and reduce delay in implementing appropriate surgical care. Review feedback to surgeons and other stakeholders should improve patient safety and quality.
authors.affiliation: Division of Research, Audit and Academic Surgery, Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, 7476, East Brisbane, Brisbane, Queensland, 4169, Australia. Electronic address: Therese.Rey-Conde@surgeons.org.
authors.forename: Therese
authors.initials: T
authors.lastname: Rey-Conde
authors.affiliation: Department of Surgery, Logan Hospital, Logan City, Queensland, Australia.
authors.forename: Arkadiusz P
authors.initials: AP
authors.lastname: Wysocki
authors.affiliation: Division of Research, Audit and Academic Surgery, Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, 7476, East Brisbane, Brisbane, Queensland, 4169, Australia.
authors.forename: John B
authors.initials: JB
authors.lastname: North
authors.affiliation: Division of Research, Audit and Academic Surgery, Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, 7476, East Brisbane, Brisbane, Queensland, 4169, Australia.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Allen
authors.affiliation: Department of Epidemiology and Biostatistics, The University of Queensland, School of Public Health, Brisbane, Queensland, Australia.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Ware
authors.affiliation: School of Medicine, Deakin University and Barwon Health, Geelong Hospital, Victoria, Australia.
authors.forename: David A
authors.initials: DA
authors.lastname: Watters
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D054869:Clinical Audit; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D061214:Patient Safety; D010380:Peer Review; D058996:Quality Improvement; D013043:Specialties, Surgical / Q000706:statistics & numerical data; D066231:Surgeons; D013514:Surgical Procedures, Operative / Q000401:mortality*; D055815:Young Adult
keywords: Clinical audit; Clinical event; Patient safety; Peer review; Surgical mortality