More than 99% of surgical deaths and complications occur outside the operating room, and patients’ own reports of how they feel may be the most critical signal we’re missing.
Vonda Vaden Bates
Patients for Patient Safety US; Anesthesia Patient Safety Foundation
Steven L. Coffee, M.A., EMCQSL
Patients for Patient Safety US; Head2Heart Connections; Anesthesia Patient Safety Foundation
Della M. Lin, M.D., M.S., FASA
Board Member and Secretary, Anesthesia Patient Safety Foundation
More than 30 million surgeries are performed annually in the United States. Thanks to modern anesthesia and surgical advances, patient deaths during the operation itself are now extremely rare.
Yet, the intra-operative period represents only a tiny fraction of the patient’s surgical journey — less than 1% of the 30-day perioperative mortality metric used to assess quality. More than 99% of deaths and complications occur outside the operating room, driven by events like bleeding, cardiac injury, infection, and other complications that may unfold long after surgery.
Clinicians and the public are realizing that our traditional view of surgical safety must expand beyond the operating room. We must amplify our focus on the signals of safety during recovery and especially after discharge, when clinical visibility drops.
The patient’s experience as a vital sign
These important signals include our patients’ vital signs. Traditionally, we use vital signs as physical measures of health that guide clinical actions and outcomes. Changes in heart rate, blood pressure, respiratory rate, and oxygenation all reflect a patient’s system under stress. However, the patient’s lived experience is a different set of vital signs that is often overlooked.
When patients and their family members say, “This doesn’t feel or look right” — noting changes in energy levels, mood, appetite, sleep, or pain patterns — they are often detecting subtle deviations that precede measurable decompensation and harm. When these time-sensitive and context-rich signals are dismissed as expected discomfort, anxiety, or noise, the system loses a critical opportunity to intervene early.
Actions to encourage safer perioperative care
| Action | How it helps |
| Patients and their families | |
| Track daily symptoms (pain, sleep, appetite, mood, energy) in a notebook or secure app | Creates a structured record for clinicians to review quickly. |
| Set red-flag thresholds (e.g., fever > 100.4°F, new shortness of breath, uncontrolled pain) | Gives clear guidance on when to call the care team |
| Clinicians | |
| Educate patients pre-operatively about which symptoms matter most and how to report them | Sets expectations and establishes a patient partnership for timely, coordinated recovery |
| Create multidisciplinary trigger alerts that combine traditional and remote monitoring data with patient narratives to triage urgency | Merges objective and subjective data for timely decision-making |
| Health organizations | |
| Integrate patient-reported outcomes into the EHR as a dedicated “patient voice” field | Widens situational awareness and makes information visible at the point of care |
| Provide staff training on interpreting patient-reported signals and integrating them into the care plan | Builds a culture where the patient voice is treated as a vital sign |
This is a call to expand what we consider actionable vital signs. This is a call for technology to amplify the patient and family voice as integral members of the healthcare team. This fall, the Anesthesia Patient Safety Foundation’s Stoelting Conference will explore this very topic. Partnering with patients and elevating their voices to the level of a vital sign is critical to prevent harm in the very period when patients are most vulnerable. Let’s intentionally design safer care together.
