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The deadliest time for many surgery patients isn’t when they’re on the operating table, it’s while they’re recovering in the hospital and after they go home, a new study published in the Canadian Medical Association Journal (CMAJ) suggests.

For the study, researchers examined outcomes for more than 40,000 patients 45 and older who underwent non-cardiac surgery at 28 hospitals in 14 countries. Researchers monitored patients for complications and deaths within 30 days of surgery.Overall, five people, or less than 1% of patients, died in the operating table, and another 500 patients, or 70%, died in the hospital. Another 210 deaths, or 29%, didn’t happen until after patients were sent home.

Nearly half of all the deaths were associated with three complications: major bleeding, heart damage, and bloodstream infections.

“Many families anxiously wait to hear from the surgeon whether their loved one survived the operation, but our research demonstrates that very few of the deaths occur in the operating room,” said Dr. P.J. Devereaux, senior author of the study and director of the Division of Perioperative Care at McMaster University in Canada.

“Our research now demonstrates that there is a need to focus on postoperative care and transitional care into the home setting to improve outcomes,” Devereaux said by email.

A wide range of technological and medical advances have made surgery safer and less invasive in recent years, the study team notes. But at the same time, patients also are coming to the hospital sicker and being sent home with complex care needs that once would have meant a lengthy hospital stay.

Patients who experienced major bleeding after surgery were more than twice as likely to die within 30 days as people who didn’t have this complication. And patients who developed heart injuries even though they didn’t have heart surgery were also more than twice as likely to die.

Patients who got sepsis, a serious bloodstream infection, were more than five times more likely to die within 30 days than people who didn’t get these infections.

Inflammation may be a common denominator in the complications that were most responsible for deaths, said Barnaby Charles Reeves of the University of Bristol in the U.K., author of an editorial accompanying the study. “Surgery causes a body-wide inflammatory reaction,” Reeves said by email. “This can lead to single or multi-organ failure (kidney, heart, lungs, sepsis etc.) which leads to death.”

Patients may also not recognize that something is wrong when they’re coming off anesthesia or taking narcotic painkillers after surgery, Devereaux said. “This makes patients after surgery vulnerable to delays in recognizing complications and hence delays in treatment,” Devereaux said.