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Dissociation of the Confounding Influences of Expectancy and Integrative Difficulty Residing in Anomalous Sentences in Event-related Potential Studies

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Case Difficulty and Non-Routine Events by Surgical Team Members in a Large Prospective Observational Study at 5

Matthew B Weinger^1,2,3, Jason S Slagle^1,2,3, Jessica Feinleib⁴

¹Geriatric Research Education and Clinical Center, VA Medical Center, VA Tennessee Valley Healthcare System.

Journal of Patient Safety

|January 26, 2026

Abstract

Background:

Excessive workload is associated with degraded operator performance and outcomes. The construct of surgical "team workload" is poorly specified, and anesthesiologist workload has rarely been measured concurrent with that of operating room nurses and surgeons during the same cases. We sought to measure workload, operationalized as individual and team "case difficulty," as well as the occurrence of non-routine events, from all surgical team members.

Methods:

This multicenter prospective observational study at 5 Veterans Affairs medical centers involved 1107 non-cardiac surgical procedures. Individual and team "case difficulty" ratings (1 "very easy" to 10 "very difficult") and the reported occurrence of non-routine events (ie, deviations from optimal care) were independently collected through facilitated survey from surgeons, anesthesia professionals, and operating room nurses before incision (pre-case) and again after skin closure (post-case).

Results:

At least one non-routine event was reported by at least one team member in 464 (42.0%) of the cases. Overall, nurses were the most likely to report an NRE (in 57% of NRE-containing cases), whereas surgeons were the least likely (40%). Anesthesia professionals and nurses had similar ratings for both the pre-case and post-case difficulty ratings. Surgeons' pre-case and post-case difficulty ratings were at least one unit greater than either of the other two OR team members ( P <0.01). Post-case, anesthesia and nursing team difficulty ratings were at least 0.4 units higher than individual ratings ( P <0.01), whereas surgeons' pre-case and post-case ratings were similar. Only nurses' individual case difficulty ratings were significantly lower post-case versus pre-case. Individual role and team case difficulty ratings were both associated with the reporting of non-routine events.

Conclusions:

Capturing surgical team case difficulty ratings and non-routine events is feasible and may shed insight into factors affecting surgical performance. In particular, pre-case difficulty ratings may be a complementary predictor of surgical risk.

Keywords:

non-routine event quality of care surgery workload

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