In Reply We would like to thank Cheun 1 for their thoughtful engagement and for highlighting several important considerations in the letter relating to our recent publication 2. The author is correct, through the Australian and New Zealand Audit of Surgical Mortality (ANZASM) process, surgical deaths are assigned to the treating or admitting surgeon, regardless of whether the deceased patient underwent an operation performed by that surgeon, or patient deterioration was the result of surgical care provided 3. This attribution reflects administrative responsibility, not responsibility for harm. Accordingly, the identification of fatal non-technical errors (NTEs) within each specialty does not imply surgeon responsibility. Still, the marked variation in NTE rates between specialties suggests that factors such as patient mix and clinical pathways influence error occurrence across disciplines. This has not previously been demonstrated and warrants further exploration. The correspondent notes that the System for Identification and Categorization of Non-technical Error in Surgical Settings (SICNESS) tool identifies NTEs as documented and cannot determine team responsibility or phase of care within which errors occur. In our study, the SICNESS tool was applied to the reports of ANZASM first- and second-line assessors. These assessors synthesise the surgical case form provided by the surgeon involved with patient care and, when required, review the full medical record, allowing reconstruction of a longitudinal, cross-team account of care from presentation to death. This process enables identification of both the clinical phase (pre-operative, intra-operative or post-operative) and the team involved 4, 5. However, analysing NTEs by team, phase and specific behaviours was beyond the scope of this publication. We agree that retrospective documentation may preferentially capture decision-making and situational awareness errors, partly explaining the domain-level discordance, communication/teamwork and leadership errors were also evident. Many, however, were classified as resultant rather than primary NTEs, consistent with SICNESS definitions and thus not reported in the current study 6. Finally, echoing the correspondent's comments, specialty-level differences should not be interpreted as comparative performance metrics. Rather, they reflect differing care environments and system structures. Although NTE incidence was universally high, and we agree that national non-technical skill improvement should be mandated, identifying specialty-level differences is a substantial first step in understanding how, when and why NTEs occur. The next step is to investigate NTEs at the specialty, pathway, team (surgical and non-surgical) and behavioural level to define targets for meaningful system-level improvement. Jesse Ey: writing (original draft) and writing (review and editing). Guy J. Maddern: writing (original draft) and writing (review and editing). The authors have nothing to report. Commissioned; not externally peer reviewed. The authors declare no conflicts of interest. This article includes no original data.
Ey et al. (Sun,) studied this question.