Cardiac surgical patients experience one of the most complex journeys in modern healthcare, involving multiple teams, multiple settings and multiple handovers. The average UK cardiac surgical patient will have between 60 to 80 individual clinical encounters with up to 15 different healthcare professional groups and will undertake over 150 distinct interactions in a typical patient journey from presentation to discharge! Patients undergoing coronary artery bypass grafting, valve or aortic surgery move through assessment, imaging, multidisciplinary decision-making, pre-operative optimisation, anaesthesia, cardiopulmonary bypass, cardiac intensive care and rehabilitation. Every transition creates risk: the operative plan must remain clear, antithrombotic medicines managed precisely, perfusion and myocardial protection verified, and complications such as bleeding, tamponade, low cardiac output, stroke, arrhythmia, infection and acute kidney injury need to be recognised early.
Cardiac surgery has a distinctive safety history. The UK national cardiac surgical register began in 1977, followed by hospital- and surgeon-level outcome reporting. Lessons from the Bristol inquiry strengthened a culture of audit, risk adjustment, transparency and continuous improvement.
The safety record is reassuring but demands continued vigilance. Despite an older and higher-risk population, UK mortality for isolated CABG fell to about 1.0% overall and 0.6% for elective surgery in national data from 2002–2016. Such outcomes reflect not only operative skill, but also reliable systems, multidisciplinary teamwork, improved monitoring and rapid rescue when complications occur.
As a cardiothoracic surgeon with an interest in Human Factors, Team-Based Quality Review (TBQR) and non-technical skills, I have learned that safety rarely depends on one operation or a single clinician. It is the product of the interaction of people, tasks, technology, organisation and environment across the whole patient journey.
Patient safety begins well before the patient enters theatre. It includes heart-team decision-making; appropriate selection and timing; optimisation of anaemia, diabetes, nutrition, renal function, heart failure and frailty; smoking cessation and prehabilitation; infection-source review where relevant; and an explicit plan for antiplatelet, anticoagulant and cardiovascular medicines. Risk-adjusted consent should address survival, stroke, bleeding, renal injury, infection and recovery.
The peri-operative phase is packed with the most interactions, and perhaps offers the clearest demonstration that surgery is a team sport. Excellent technical performance remains essential, but successful outcomes depend equally on communication, leadership, situational awareness and teamwork. Majority of the time, when things go well, patients rarely see the hundreds of small safety-critical interactions occurring around them. When things go wrong, failures in communication often feature somewhere in the story.
In theatre, prevention requires a cardiac brief and checklist; confirmation of the procedure, imaging and graft or valve strategy; antimicrobial prophylaxis; blood conservation; precise anticoagulation and reversal; effective myocardial protection; and perfusion that supports oxygen delivery and organ function. During separation from bypass or crisis, communication, leadership, situational awareness and speaking up are as important as technical expertise.
After surgery, good outcomes depend on surveillance and rescue. Teams must respond rapidly to bleeding, tamponade, low cardiac output, ischaemia, atrial fibrillation, stroke, respiratory deterioration, infection and acute kidney injury. Prevention of complications include maintaining organ perfusion and euvolaemia, avoiding nephrotoxins where possible, pulmonary care, early mobilisation, appropriate thromboprophylaxis, glycaemic control and medication reconciliation.
Perhaps the most underappreciated stage of the pathway is discharge and rehabilitation. Leaving hospital is not the end of the patient journey; it is another transfer of care. Effective communication with general practitioners, community teams, cardiac rehabilitation services, patients and families is essential. Safe discharge requires clear plans for antithrombotic therapy, diuretics, rhythm management, wound and weight monitoring, rehabilitation, red flags and follow-up. Success should be measured beyond mortality figures; morbidity including stroke, reoperation, renal replacement therapy, readmission, deep sternal wound infection, all impact functional recovery and quality of life.
Most patient harm does not arise because individuals lack knowledge or commitment. It occurs because healthcare systems are complex, information is fragmented and opportunities for misunderstanding are plentiful. Rather than asking, "Who made the mistake?", we should be asking, "How did the system allow this to happen?" and “What barriers and safeguards are needed to reduce recurrence?”
The Royal College of Surgeons of Edinburgh supports this approach through NOTSS, PINTS and TBQR, reinforcing that safer surgery depends on culture, teamwork and learning as much as technical skill.
This World Patient Safety Day, the cardiac-surgery challenge is clear: protect the whole pathway, not only the operation. Every heart-team decision, perfusion plan, brief, handover, escalation, prescription and rehabilitation review is a safety intervention. Further gains will come from combining technical excellence with reliable systems, real-time learning and Human Factors principles.
My call to action is practical: every cardiac surgical unit should train the full multidisciplinary team in non-technical skills, examine outcomes beyond mortality, use risk-adjusted data to identify variation, strengthen information transfer, involve patients and families, and convert learning from both excellent recoveries and adverse events into sustained improvement.
Nishan Fernando
Cardiothoracic Specialist and Honorary Lecturer University of Aberdeen
RCSEd role: Executive Committee Member of the Faculty of Perioperative Care, Member Cardiothoracic Surgical Specialty Board and SASL Committee, Scoring Panel Member and MRCS Examiner for the Intercollegiate Committee for Basic Surgical Exams (ICBSE)
