To define the prevalence of tracheotomy tube complications and evaluate risk factors (RFs) associated with their occurrence. Multi-institution historical cohort. Data regarding tracheotomy tube complications from consecutive surgeries performed across eight participating institutions between January 1, 2008 and December 31, 2009 were retrospectively collected. Patient demographics, comorbidities, physician specialty, and surgical technique were recorded and statistically analyzed to identify the incidence of surgical complications following tracheotomy and associated RFs. The charts of 1,175 tracheotomy procedures were reviewed from eight academic institutions. Otolaryngologists performed 66.2% of the tracheotomies. Intraoperative, early (<1 week), and late complication rates were 1.4%, 5.6%, and 7.1%, respectively. Postoperative bleeding was identified as the most common early complication (2.6%), whereas airway stenosis was the most common late complication (1.7%). The use of outer flange security sutures to anchor the tracheostomy tube was negatively associated with the incidence of early complication (P<.0001). The use of large endotracheal tubes (size>7.5) and obesity were associated with the development of airway stenosis (P<.05).Twenty-two percent of patients undergoing tracheotomy died during hospitalization. Perioperative tracheotomy complications are rare; however, the rate of death for all causes is high (22%) in this population. Obesity and the use of endotracheal tubes over 7.5 in size are major risk factors for the development of airway stenosis. Although percutaneous tracheotomy resulted in a significantly higher rate of postoperative bleeding (6.6%) than the open method (1.9%) (P<.05), the use of outer flange tracheostomy tube sutures may reduce this complication. Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.