Complications vs. Standard of Care: What Surgical Peer Review Really Evaluates

Surgical care inherently involves risk. Even when procedures are performed by experienced surgeons following accepted practices, complications may occur. Despite this reality, adverse outcomes are frequently—and incorrectly—equated with substandard care. This misunderstanding can undermine fair evaluation, distort quality improvement efforts, and contribute to a punitive culture rather than a learning-focused one.

Surgical peer review exists to address this distinction by evaluating whether care met the standard of care, not whether the outcome was ideal.

Complications Are an Expected Part of Surgical Practice

Complications span a wide range, from minor postoperative issues to severe and life-threatening events. Many are well-recognized risks associated with otherwise appropriate procedures and occur despite adherence to best practices.

Examples include:

• Postoperative bleeding

• Surgical site infections despite appropriate prophylaxis

• Nerve injury during anatomically complex operations

• Anastomotic leaks or wound complications

The occurrence of such events does not, by itself, indicate that care was inappropriate. Surgical peer review recognizes that complications can occur even when care is properly delivered.

Defining the Standard of Care

The standard of care is not defined by perfection or the absence of complications. Rather, it reflects what a reasonably prudent surgeon would have done under similar circumstances, based on the knowledge, resources, and clinical information available at the time.

Key elements include:

• Appropriateness of the surgical indication

• Adequacy of preoperative evaluation and planning

• Sound intraoperative judgment and technique

• Appropriate postoperative monitoring and management

Importantly, the standard of care allows for clinical variability. Different surgeons may reasonably approach the same clinical scenario in different ways, all while meeting accepted standards.

The Role of Judgment Over Outcome

Surgical peer review focuses on clinical decision-making, not retrospective outcome-based conclusions. A poor outcome does not retroactively invalidate decisions that were reasonable when made.

High-quality peer review asks:

• Were decisions consistent with accepted practice at the time?

• Were risks appropriately considered and communicated?

• Were intraoperative findings managed in a reasonable manner?

• Was postoperative care responsive to the patient’s condition?

This approach ensures that evaluations are grounded in professional judgment rather than outcome bias.

Avoiding Hindsight Bias

One of the most significant challenges in peer review is hindsight bias—the tendency to judge past decisions based on information that became available only after the outcome was known.

Effective peer review requires reviewers to evaluate care as it unfolded, not as it appears in retrospect. Decisions must be assessed using the clinical context, diagnostic information, and patient condition present at the time they were made.

Avoiding hindsight bias is essential to maintaining fairness, credibility, and trust in the peer review process.

Documentation and Its Impact on Peer Review

While clinical care may be appropriate, insufficient documentation can complicate peer review and create ambiguity about decision-making. Common documentation issues include:

• Incomplete or vague operative reports

• Lack of explanation for intraoperative decisions

• Insufficient documentation of informed consent

• Delayed or unclear documentation of postoperative assessments

Peer review evaluates both the quality of care provided and whether the medical record accurately reflects sound clinical reasoning. Clear documentation supports transparency and demonstrates adherence to the standard of care.

Postoperative Management Is Central to Evaluation

Surgical peer review extends beyond the operating room. Many adverse outcomes are influenced by postoperative recognition, communication, and response.

Key considerations include:

• Timely identification of complications

• Appropriate escalation of care

• Coordination among surgical, nursing, and consulting teams

• Responsiveness to changes in patient condition

Even when complications occur, prompt and appropriate management often reflects high-quality care.

The Importance of Subspecialty Expertise

Assessing standard of care in surgery requires expertise relevant to the specific procedure and clinical context. Subspecialty-trained reviewers are better equipped to evaluate:

• Procedure-specific risks

• Accepted technical variations

• Expected complication profiles

• Complex intraoperative decision-making

Peer review grounded in relevant clinical experience ensures more accurate, credible, and defensible conclusions.

The Purpose of Surgical Peer Review

The goal of surgical peer review is not punishment, but improvement. When conducted appropriately, it:

• Differentiates complications from true deviations in care

• Supports professional accountability

• Identifies opportunities for system-level improvement

• Promotes a culture of learning and patient safety

By focusing on clinical judgment, context, and standards rather than outcomes alone, peer review becomes a constructive and essential component of surgical quality assurance.