Caring for the Care-Giver: Debriefing Following Intra-Operative Death

  • Roy Soto
  • Julie Kado
  • Bryan Kerner
  • Paul O'Leary
  • Gerald Rosen


Intraoperative death affects a team of individuals, each with different levels of training and experience.  Although briefings, time-outs, and debriefings have been well described, it is unclear how often they occur following intraoperative catastrophic events. We utilized an electronic survey to assess the frequency and potential utility of a formal debriefing process following the intraoperative death of a patient, and discuss our findings in light of the mental well-being of perioperative medical personnel.   An electronic survey was distributed to OR staff in two hospital systems. The survey was designed to identify which staff members had experienced intraoperative loss, what response was elicited, and what resources were available to them following this event.  Of the 196 people who responded to the survey, over half (56%) had experienced the loss of a patient in the OR.  80% of those who had experienced the intraoperative loss of a patient reported moderate to strong emotional responses to the event.  Almost no one reported formal support offered  following the event, yet, over 50% people felt that a formal debriefing of the entire team would have helped either themselves or others members cope with the death. Over 85% of team members felt that the most effective strategy in reducing stress following intra-operative patient death is talking to co-workers.  Over 80% of team members felt that their activities of daily living and relationships were not interrupted following the event.  Our survey confirms that a lack of resources is available for health professionals after a catastrophic intraoperative event.

Quality Research Manuscript: Non-Resident