Code Surgical Emergency Team (SET) is the “Missing Code:” An Emerging Perioperative Hemorrhage Best Practice

OBJECTIVES: Managing the heightened risks of hemorrhage and hematoma vital organ compression due to surgical complications is a challenge for health care systems pursuing the ultimate goal of Zero Harm. Although a certain number of surgical complications are expected, the catastrophic outcomes that ensue are often preventable. This paper aims to contribute to the understanding of processes to address perioperative hemorrhage morbidity and mortality. METHODS: The authors first identified a broad opportunity to optimize surgical safety in the Veterans Health Administration through perioperative hemorrhage Root Cause Analysis studies from 2022 to 2023. In 2023, we verified and defined risk pain points through task analysis and identified and optimized a solution through iterative rounds of simulation from 2023 to 2024. RESULTS: Code Surgical Emergency Team (Code SET), a hospital-wide activation of existing personnel, resources, and services to implement emergency clauses in perioperative safety protocols, was designed to address gaps in quality and safety through 7 process steps: (1) activation; (2) code announcement; (3) kit mobilization; (4) activation of emergency clauses; (5) anesthetic and surgical care; (6) poststability pause; and (7) debrief and review. CONCLUSION: In this paper, we describe the implementation of a comprehensive surgical safety package to reduce perioperative morbidity and mortality. Preliminary pilot findings suggest that the Code SET process may reduce surgical patient morbidity and mortality and improve outcomes. This process demonstrates how institutions can use existing resources in a standardized approach to improving patient safety.