If a coworker of a surgeon complains about unprofessional behavior in the workplace, patients are more likely to suffer with higher rates of complications, according to a recent study published in JAMA Surgery.

That’s because rude surgeons may help foster a culture that undermines safety and teamwork, increasing the risks for medical errors and surgical complications, the study, conducted by researchers from Vanderbilt University, found. Many of these reports from coworkers come from nurses, who are well-positioned to observe surgeons’ behavior. The findings may help healthcare providers better understand the risks of delivering quality care.

Researchers included 13,653 patients in the cohort study who underwent surgeries by 202 surgeons. Of the study group, 1,583, or 11.6%, experienced a complication, and those that did were far more likely to have a surgeon with more coworker reports. The complication rate among patients of surgeons with one to three reports was 14.3% higher and 11.9% higher for patients with a surgeon with four or more reports compared to surgeons with no reports in the 36 months before an operation.

The study looked at data from two big academic health systems that participate in the American College Surgeons National Surgical Quality Program (NSQIP) with electronic event-reporting systems.