{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T13:02:55Z","timestamp":1792414975180,"version":"4.4.0"},"reference-count":40,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2023,3,28]],"date-time":"2023-03-28T00:00:00Z","timestamp":1679961600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Intraoperative adverse events (iAEs) are associated with adverse postoperative outcomes and cause a significant healthcare burden. However, a critical appraisal of iAEs is lacking. Considering the details of iAEs could benefit postoperative care. We comprehensively analyzed iAEs in a large series including all types of operations and their relation to postoperative complications. Methods: All patients enrolled in the multicenter ClassIntra\u00ae validation study (NCT03009929) were included in this analysis. The surgical and anesthesia team prospectively recorded all iAEs. Two researchers, blinded to each other\u2019s ratings, appraised all recorded iAEs according to their origin into four categories: surgery, anesthesia, organization, or other, including subcategories such as organ injury, arrhythmia, or instrument failure. They further descriptively analyzed subcategories of all iAEs. Postoperative complications were assessed using the Comprehensive Complication Index (CCI\u00ae), a weighted sum of all postoperative complications according to the Clavien\u2013Dindo classification. The association of iAE origins in addition to the severity grade of ClassIntra\u00ae on CCI\u00ae was assessed with a multivariable mixed-effects generalized linear regression analysis. Results: Of 2520 included patients, 778 iAEs were recorded in 610 patients. The origin was surgical in 420 (54%), anesthesia in 283 (36%), organizational in 34 (4%), and other in 41 (5%) events. Bleeding (n = 217, 28%), hypotension (n = 118, 15%), and organ injury (n = 98, 13%) were the three most frequent subcategories in surgery and anesthesia, respectively. In the multivariable mixed-effect analysis, no significant association between the origin and CCI\u00ae was observed. Conclusion: Analyzing the type and origin of an iAE offers individualized and contextualized information. This detailed descriptive information can be used for targeted surveillance of intra- and postoperative care, even though the overall predictive value for postoperative events was not improved by adding the origin in addition to the severity grade.<\/jats:p>","DOI":"10.3390\/jcm12072546","type":"journal-article","created":{"date-parts":[[2023,3,28]],"date-time":"2023-03-28T06:15:15Z","timestamp":1679984115000},"page":"2546","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Appraisal of Intraoperative Adverse Events to Improve Postoperative Care"],"prefix":"10.3390","volume":"12","author":[{"given":"Larsa","family":"Gawria","sequence":"first","affiliation":[{"name":"Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands"},{"name":"Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, 4051 Basel, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmed","family":"Jaber","sequence":"additional","affiliation":[{"name":"Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands"},{"name":"Department of Surgery, Yitzhak Shamir Medical Centre, Tel Aviv 7030083, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4012-7968","authenticated-orcid":false,"given":"Richard Peter Gerardus","family":"Ten Broek","sequence":"additional","affiliation":[{"name":"Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianmaria","family":"Bernasconi","sequence":"additional","affiliation":[{"name":"Clinic for Anesthesiology and Pain Therapy, Hospital of Fribourg, 1752 Fribourg, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel","family":"Rosenthal","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Basel, 4001 Basel, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0323-4876","authenticated-orcid":false,"given":"Harry","family":"Van Goor","sequence":"additional","affiliation":[{"name":"Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7219-7138","authenticated-orcid":false,"given":"Salome","family":"Dell-Kuster","sequence":"additional","affiliation":[{"name":"Department of Surgery, Yitzhak Shamir Medical Centre, Tel Aviv 7030083, Israel"},{"name":"Clinic for Anesthesiology, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, 4031 Basel, Switzerland"},{"name":"Department of Clinical Research, University of Basel, 4031 Basel, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1056\/NEJM199102073240605","article-title":"The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II","volume":"324","author":"Leape","year":"1991","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1097\/00005650-200003000-00003","article-title":"Incidence and types of adverse events and negligent care in Utah and Colorado","volume":"38","author":"Thomas","year":"2000","journal-title":"Med. Care"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1067\/msy.1999.98664","article-title":"The incidence and nature of surgical adverse events in Colorado and Utah in 1992","volume":"126","author":"Gawande","year":"1999","journal-title":"Surgery"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1097\/SLA.0b013e31826f4969","article-title":"Adhesiolysis-related morbidity in abdominal surgery","volume":"258","author":"Strik","year":"2013","journal-title":"Ann. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1196","DOI":"10.1016\/S0140-6736(09)61460-4","article-title":"Ageing populations: The challenges ahead","volume":"374","author":"Christensen","year":"2009","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1887","DOI":"10.1016\/S0140-6736(12)60516-9","article-title":"Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: A multicentre, open-label, randomised controlled trial","volume":"379","author":"Biere","year":"2012","journal-title":"Lancet"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2379","DOI":"10.1007\/s00268-019-05048-1","article-title":"Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review","volume":"43","author":"Jung","year":"2019","journal-title":"World J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1097\/01.sla.0000133083.54934.ae","article-title":"Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey","volume":"240","author":"Dindo","year":"2004","journal-title":"Ann. Surg."},{"key":"ref_9","first-page":"1","article-title":"Standardizing The Intraoperative Adverse Events Assessment to Create a Positive Culture of Reporting Errors in Surgery and Anesthesiology","volume":"275","author":"Cacciamani","year":"2022","journal-title":"Ann. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1431","DOI":"10.1002\/bjs.7576","article-title":"Operative notes do not reflect reality in laparoscopic cholecystectomy","volume":"98","author":"Wauben","year":"2011","journal-title":"Br. J. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1002\/bjs.8994","article-title":"Comparison of operative notes with real-time observation of adhesiolysis-related complications during surgery","volume":"100","year":"2013","journal-title":"Br. J. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1097\/SLA.0b013e3181dc3656","article-title":"Postoperative handover: Problems, pitfalls, and prevention of error","volume":"252","author":"Nagpal","year":"2010","journal-title":"Ann. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/j.jamcollsurg.2006.11.011","article-title":"An Apgar score for surgery","volume":"204","author":"Gawande","year":"2007","journal-title":"J. Am. Coll. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1120","DOI":"10.1016\/j.jamcollsurg.2013.12.060","article-title":"Derivation and validation of a novel severity classification for intraoperative adverse events","volume":"218","author":"Kaafarani","year":"2014","journal-title":"J. Am. Coll. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2159","DOI":"10.1007\/s00464-020-07621-5","article-title":"Clinical adhesion score (CLAS): Development of a novel clinical score for adhesion-related complications in abdominal and pelvic surgery","volume":"35","author":"Lier","year":"2021","journal-title":"Surg. Endosc."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"3822","DOI":"10.1007\/s00464-018-6108-1","article-title":"EAES classification of intraoperative adverse events in laparoscopic surgery","volume":"32","author":"Francis","year":"2018","journal-title":"Surg. Endosc."},{"key":"ref_17","first-page":"m2917","article-title":"Prospective validation of classification of intraoperative adverse events (ClassIntra): International, multicentre cohort study","volume":"370","author":"Gomes","year":"2020","journal-title":"BMJ"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1570","DOI":"10.1016\/j.surg.2021.12.011","article-title":"Classification of intraoperative adverse events in visceral surgery","volume":"171","author":"Gawria","year":"2022","journal-title":"Surgery"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1136\/qshc.2007.022400","article-title":"Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: Results from the National Reporting and Learning System","volume":"18","author":"Hutchinson","year":"2009","journal-title":"Qual. Saf. Health Care"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1136\/bmjqs-2013-001848","article-title":"Team-training in healthcare: A narrative synthesis of the literature","volume":"23","author":"Weaver","year":"2014","journal-title":"BMJ Qual. Saf."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1097\/SLA.0b013e3181b13ca2","article-title":"The Clavien-Dindo classification of surgical complications: Five-year experience","volume":"250","author":"Clavien","year":"2009","journal-title":"Ann. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1097\/SLA.0000000000000948","article-title":"The comprehensive complication index: A novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials","volume":"260","author":"Slankamenac","year":"2014","journal-title":"Ann. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1097\/SLA.0b013e318296c732","article-title":"The comprehensive complication index: A novel continuous scale to measure surgical morbidity","volume":"258","author":"Slankamenac","year":"2013","journal-title":"Ann. Surg."},{"key":"ref_24","unstructured":"American Society of Anesthesiologists (2021, March 03). ASA Physical Status Classification System [ASA Web Site]. Available online: https:\/\/www.asahq.org\/resources\/clinical-information\/asa-physical-status-classification-system."},{"key":"ref_25","unstructured":"(2021, July 07). BUPA (British United Provident Association): Schedule of Procedures. Available online: https:\/\/bupa.secure.force.com\/procedures."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/S0196-6553(99)70088-X","article-title":"Guideline for Prevention of Surgical Site Infection, 1999","volume":"27","author":"Mangram","year":"1999","journal-title":"Am. J. Infect. Control"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"717","DOI":"10.1007\/s00464-018-6254-5","article-title":"Characterization of device-related interruptions in minimally invasive surgery: Need for intraoperative data and effective mitigation strategies","volume":"33","author":"Jung","year":"2019","journal-title":"Surg. Endosc."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2512","DOI":"10.1007\/s00464-015-4512-3","article-title":"Microcomplications in laparoscopic cholecystectomy: Impact on duration of surgery and costs","volume":"30","author":"Hoffmann","year":"2016","journal-title":"Surg. Endosc."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1048","DOI":"10.1016\/j.jamcollsurg.2016.12.039","article-title":"The Surgeon as the Second Victim? Results of the Boston Intraoperative Adverse Events Surgeons\u2019 Attitude (BISA) Study","volume":"224","author":"Han","year":"2017","journal-title":"J. Am. Coll. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1677","DOI":"10.1056\/NEJMp1303960","article-title":"Improving Patient Safety through Transparency","volume":"369","author":"Kachalia","year":"2013","journal-title":"N. Engl. J. Med."},{"key":"ref_31","unstructured":"(2023, January 22). Sentinel Event Analysis Statistics. 1995\u20132004. Available online: http:\/\/www.jointcomission.org."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1056\/NEJMsa0810119","article-title":"A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population","volume":"360","author":"Haynes","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1016\/j.bja.2021.08.023","article-title":"Six Sigma in surgery: How to create a safer culture in the operating theatre using innovative technology","volume":"127","author":"Strandbygaard","year":"2021","journal-title":"Br. J. Anaesth."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1016\/j.amjsurg.2021.07.043","article-title":"The surgical debrief: Just another checklist or an instrument to drive cultural change?","volume":"223","author":"Leonard","year":"2022","journal-title":"Am. J. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e198067","DOI":"10.1001\/jamanetworkopen.2019.8067","article-title":"Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events","volume":"2","author":"Suliburk","year":"2019","journal-title":"JAMA Netw. Open"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1001\/jamasurg.2016.4952","article-title":"Enhanced Recovery After Surgery: A Review","volume":"152","author":"Ljungqvist","year":"2017","journal-title":"JAMA Surg."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Gomes, N.V., Polutak, A., Schindler, C., Weber, W.P., Steiner, L.A., Rosenthal, R., and Dell-Kuster, S. (2023). Discrepancy in Reporting of Perioperative Complications: A Retrospective Observational Study. Ann. Surg., published ahead of print.","DOI":"10.1097\/SLA.0000000000005807"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1016\/j.jclinepi.2013.08.015","article-title":"Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects","volume":"67","author":"McCambridge","year":"2014","journal-title":"J. Clin. Epidemiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/1754-9493-5-13","article-title":"The incidence, root-causes, and outcomes of adverse events in surgical units: Implication for potential prevention strategies","volume":"5","author":"Zegers","year":"2011","journal-title":"Patient Saf. Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1663","DOI":"10.1007\/s00268-015-3003-y","article-title":"Definition and Classification of Intraoperative Complications (CLASSIC): Delphi Study and Pilot Evaluation","volume":"39","author":"Rosenthal","year":"2015","journal-title":"World J. Surg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/7\/2546\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:04:55Z","timestamp":1760123095000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/7\/2546"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,3,28]]},"references-count":40,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2023,4]]}},"alternative-id":["jcm12072546"],"URL":"https:\/\/doi.org\/10.3390\/jcm12072546","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,3,28]]}}}