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What’s New in the Patient Safety World

July 2022

Outcomes OK When Surgeon Operated the Night Before



The role of fatigue in causing errors in healthcare or any industry is well established. But there is one glaring example that seems to defy this concept. In our September 2015 What's New in the Patient Safety World column “Surgery Previous Night Does Not Impact Attending Surgeon Next Day” we discussed a Canadian study (Govindarajan 2015) that showed outcomes for the “next day” case do not seem to be adversely impacted by the surgeon’s previous night procedures.


Now a new study (Sun 2022) from more than 50 hospitals across 18 states and 2 countries (US and the Netherlands) confirms the results seen in the Canadian study. Sun et al. looked at outcomes of almost 500,000 surgeries, of which 2.6% involved an attending surgeon who operated the night before.


After adjusting for operation type, surgeon fixed effects (indicator variables for each surgeon), and patient characteristics such as age and comorbidities, the incidence of in-hospital death or major complications was 5.89% among daytime operations when the attending surgeon operated the night before compared with 5.87% among daytime operations when the same surgeon did not. There was also no difference in several secondary outcomes studied except for a slight decrease in the length of daytime operations.


Several sensitivity analyses also suggested no difference between overnight work and the primary outcome. There was no statistically significant difference in the incidence of death or major complication for daytime procedures based on procedure length. Each additional hour worked the previous night was associated with a statistically nonsignificant decrease in the probability of death or a major complication for daytime procedures.


The authors conclude that, combined with previous studies, their results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform procedures the following morning. They state their results do not establish that this practice is always safe or that fatigue does not affect outcomes, but that the potential risk was managed well enough to avoid patient harm in this sample of

surgeons. They do note that these cases were done mostly at academic institutions and that the results may not be generalizable to other settings.


Again, this is a very different question from one we have addressed on numerous occasions. Several of our columns have questioned whether surgery should be done “after hours”, particularly for procedures that may not be true emergency ones (see our What’s New in the Patient Safety World columns for September 2009 “After-Hours Surgery – Is There a Downside?”, October 2014 “What Time of Day Do You Want Your Surgery?”, December 2014 “Another Procedure to Avoid Late in the Day or on Weekends” and January 2015 “Emergency Surgery Also Very Costly”).


In those columns we have pointed out that such surgeries and procedures involve considerations far beyond just the surgeon. Why should “after hours” surgery be more prone to adverse outcomes than regularly scheduled elective surgery? There are many reasons aside from the fact that patients needing emergency and after hours surgery are generally sicker. You are operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.


It is reassuring, however, that both the studies by Sun et al. and Govindarajan et al. seem to indicate that surgeons operating the day following a night procedure have managed potential risk well enough to avoid patient harm.



Some of our other columns on the role of fatigue in Patient Safety:


November 9, 2010      “12-Hour Nursing Shifts and Patient Safety”

April 26, 2011             “Sleeping Air Traffic Controllers: What About Healthcare?”

February 2011             “Update on 12-hour Nursing Shifts”

September 2011          “Shiftwork and Patient Safety

November 2011          “Restricted Housestaff Work Hours and Patient Handoffs”

January 2012               “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           “Unintended Consequences of Restricted Housestaff Hours”

June 2012                    “June 2012 Surgeon Fatigue”

November 2012          “The Mid-Day Nap”

November 13, 2012    “The 12-Hour Nursing Shift: More Downsides”

July 29, 2014              “The 12-Hour Nursing Shift: Debate Continues”

October 2014              “Another Rap on the 12-Hour Nursing Shift”

December 2, 2014       “ANA Position Statement on Nurse Fatigue”

August 2015               “Surgical Resident Duty Reform and Postoperative Outcomes”

September 2015          “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”

September 29, 2015    “More on the 12-Hour Nursing Shift”

September 6, 2016      “Napping Debate Rekindled”

April 18, 2017             “Alarm Response and Nurse Shift Duration”

July 11, 2017              “The 12-Hour Shift Takes More Hits”

February 13, 2018       “Interruptions in the ED”

April 2018                   “Radiologists Get Fatigued, Too”

August 2018               “Burnout and Medical Errors”

September 4, 2018      “The 12-Hour Nursing Shift: Another Nail in the Coffin”

August 2020               “New Twist on Resident Work Hours and Patient Safety”

August 25, 2020         “The Off-Hours Effect in Radiology”

September 2020          “Daylight Savings Time Impacts Patient Safety?”

January 19, 2021         “Technology to Identify Fatigue?”

October 12, 2021        “FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?”

February 2022             “Does Time of Day Matter?”


Some of our previous columns on “after-hours” surgery:

·       September 2009        “After-Hours Surgery – Is There a Downside?”

·       October 2014            “What Time of Day Do You Want Your Surgery?”

·       January 2015             “Emergency Surgery Also Very Costly”

·       September 2015        “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”

·       October 4, 2016        “More on After-Hours Surgery”

·       August 15, 2017        “Delayed Emergency Surgery and Mortality Risk”

·       October 24, 2017      “Neurosurgery and Time of Day”

·       December 2019         “Surgeon On-Call Shifts”

·       October 13, 2020      “Night-Time Surgery”







Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med 2015; 373: 845-853

(Govindarajan 2015)



Sun EC, Mello MM, Vaughn MT, et al. Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before. JAMA Intern Med 2022; Published online May 23, 2022

(Sun 2022)






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