IMPORTANCE For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications. OBJECTIVE To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019. EXPOSURES Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation. MAIN OUTCOMES AND MEASURES Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation. RESULTS Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; Ն4 reports, 294 of 2087 [14.1%]; P < .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; Ն4 reports, 159 of 2087 [7.6%]; P < .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; Ն4 reports, 196 of 2087 [9.4%]; P < .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05). CONCLUSIONS AND RELEVANCE Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient's operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.

Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.

The SCM intervention reduces medical complications, length of stay, 30-day readmissions, number of consultants, and cost of care.

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