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Cardiac surgical outcomes are some of the most scrutinised results in medicine, both by the public as well as the surgeons themselves. This has resulted in an extraordinary push for quality, and the result has been improvement year over year.1 We now recognise that complex operations have high potential for error, and that no single individual should be relied on to ensure safe care. Indeed, even for high-quality cardiac surgery programmes with excellent outcomes errors still occur, and only about 10% of patients will experience zero error or near misses after open heart surgery.2 Creating the teams and care delivery systems to minimise errors and mitigate their impact drives quality improvement. One new area of investigation that has received attention relates to variation in operative and postoperative care delivery systems with a focus on off-peak (evenings, nights and weekends) performance.3 4
With this background, Zhang and colleagues evaluate the association between procedure order (first vs non-first case) for each surgeon and complications following coronary artery bypass grafting (CABG).5 The authors hypothesise that prior workload (a prior surgical procedure in the same day) would lead to more errors and complications, particularly for higher hazard procedures such as off-pump CABG. They performed a retrospective analysis of 21 866 patients in China who underwent CABG (between 08:00 and 19:00), stratifying into off-pump and on-pump CABGs. They found that for on-pump CABG cases the order of the procedure (first vs later cases) did not impact the number of adverse events in a composite including in-hospital mortality, myocardial infarction (MI), stroke, acute kidney injury and reoperation (nor any of the individual components of the composite). For off-pump CABG operations, however, non-first cases were associated with higher risk of the adverse event composite (rate ratio 1.29) as well as on the individual components …