Patterns of Technical Error Among Surgical Malpractice Claims: An Analysis of Strategies to Prevent Injury to Surgical Patients

Objective:To identify the most prevalent patterns of technical errors in surgery, and evaluate commonly recommended interventions in light of these patterns. Summary Background Data:The majority of surgical adverse events involve technical errors, but little is known about the nature and causes of these events. We examined characteristics of technical errors and common contributing factors among closed surgical malpractice claims. Methods:Surgeon reviewers analyzed 444 randomly sampled surgical malpractice claims from four liability insurers. Among 258 claims in which injuries due to error were detected, 52% (n = 133) involved technical errors. These technical errors were further analyzed with a structured review instrument designed by qualitative content analysis. Results:Forty-nine percent of the technical errors caused permanent disability; an additional 16% resulted in death. Two-thirds (65%) of the technical errors were linked to manual error, 9% to errors in judgment, and 26% to both manual and judgment error. A minority of technical errors involved advanced procedures requiring special training (“index operations”; 16%), surgeons inexperienced with the task (14%), or poorly supervised residents (9%). The majority involved experienced surgeons (73%), and occurred in routine, rather than index, operations (84%). Patient-related complexities—including emergencies, difficult or unexpected anatomy, and previous surgery—contributed to 61% of technical errors, and technology or systems failures contributed to 21%. Conclusions:Most technical errors occur in routine operations with experienced surgeons, under conditions of increased patient complexity or systems failure. Commonly recommended interventions, including restricting high-complexity operations to experienced surgeons, additional training for inexperienced surgeons, and stricter supervision of trainees, are likely to address only a minority of technical errors. Surgical safety research should instead focus on improving decision-making and performance in routine operations for complex patients and circumstances.

[1]  Karen E McKinley,et al.  “ProvenCareSM”: A Provider-Driven Pay-for-Performance Program for Acute Episodic Cardiac Surgical Care , 2007, Annals of surgery.

[2]  Stuart R Lipsitz,et al.  Patterns of communication breakdowns resulting in injury to surgical patients. , 2007, Journal of the American College of Surgeons.

[3]  G. Velmahos,et al.  The concept of acute care surgery: a vision for the not-so-distant future. , 2007, Surgery.

[4]  Rajesh Aggarwal,et al.  Technical-skills training in the 21st century. , 2006, The New England journal of medicine.

[5]  Thomas B Sheridan,et al.  Making the Operating Room of the Future Safer , 2006, The American surgeon.

[6]  W. Pories,et al.  The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement. , 2006, Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery.

[7]  Catherine Yoon,et al.  Analysis of surgical errors in closed malpractice claims at 4 liability insurers. , 2006, Surgery.

[8]  Catherine Yoon,et al.  Claims, errors, and compensation payments in medical malpractice litigation. , 2006, The New England journal of medicine.

[9]  Caprice K. Christian,et al.  A prospective study of patient safety in the operating room. , 2006, Surgery.

[10]  M. Evans,et al.  Matching risk and resources in high-risk pregnancies , 2006, The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians.

[11]  Hsiu-Fang Hsieh,et al.  Three Approaches to Qualitative Content Analysis , 2005, Qualitative health research.

[12]  S. Fagan,et al.  Bridging the communication gap in the operating room with medical team training. , 2005, American journal of surgery.

[13]  E. Salas,et al.  Using Simulation-Based Training to Improve Patient Safety : What Does It Take ? Human Factors Engineering , 2005 .

[14]  W. Henderson,et al.  The Impact of Operative Complexity on Patient Risk Factors , 2005, Annals of surgery.

[15]  L. Neumayer,et al.  Does Resident Post Graduate Year Influence the Outcomes of Inguinal Hernia Repair? , 2005, Annals of surgery.

[16]  J. Prystowsky.  Are young surgeons competent to perform alimentary tract surgery? , 2005, Archives of surgery.

[17]  Kaiser Lr,et al.  ACS Surgery: Principles and Practice , 2005 .

[18]  D. Flum,et al.  Impact of gastric bypass operation on survival: a population-based analysis. , 2004, Journal of the American College of Surgeons.

[19]  R. Reznick,et al.  Communication failures in the operating room: an observational classification of recurrent types and effects , 2004, Quality and Safety in Health Care.

[20]  Thomas B. Sheridan,et al.  Using field observations as a tool for discovery: analys ing cognitive and collaborative demands in the operating room , 2004, Cognition, Technology & Work.

[21]  Charles Vincent,et al.  Systems Approaches to Surgical Quality and Safety: From Concept to Measurement , 2004, Annals of surgery.

[22]  José Orlando Gomes,et al.  Handoff strategies in settings with high consequences for failure: lessons for health care operations. , 2004, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[23]  Robert E Harbaugh,et al.  Surgeon Volume and Operative Mortality in the United States. , 2004, Neurosurgery.

[24]  David M Studdert,et al.  Analysis of errors reported by surgeons at three teaching hospitals. , 2003, Surgery.

[25]  M.Sc. Edward Etchells M.D.,et al.  Patient Safety in Surgery: Error Detection and Prevention , 2003, World Journal of Surgery.

[26]  J. M. King.  Anaesthesia for the High Risk Patient , 2002 .

[27]  David M Gaba,et al.  Patient safety: fatigue among clinicians and the safety of patients. , 2002, The New England journal of medicine.

[28]  Thomas H. Lee.  Proving and improving the value of consultations. , 2002, The American journal of medicine.

[29]  J. Bagian,et al.  The Veterans Affairs root cause analysis system in action. , 2002, The Joint Commission journal on quality improvement.

[30]  Patrick S Romano,et al.  Can Administrative Data Be Used to Compare Postoperative Complication Rates Across Hospitals? , 2002, Medical care.

[31]  Ethan A Halm,et al.  Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature , 2002, Annals of Internal Medicine.

[32]  J. Birkmeyer,et al.  Hospital volume and surgical mortality in the United States. , 2002, The New England journal of medicine.

[33]  D. Creasey.  Anaesthesia for the High Risk Patient , 2002 .

[34]  Art Noda,et al.  Kappa coefficients in medical research , 2002, Statistics in medicine.

[35]  S. Guerlain,et al.  A systems approach to surgical safety , 2002, Surgical Endoscopy And Other Interventional Techniques.

[36]  Kwan Hur,et al.  Identifying patient preoperative risk factors and postoperative adverse events in administrative databases: results from the Department of Veterans Affairs National Surgical Quality Improvement Program. , 2002, Journal of the American College of Surgeons.

[37]  E. Hannan,et al.  The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer. , 2002, Surgery.

[38]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[39]  K. McDonald,et al.  Making health care safer: a critical analysis of patient safety practices. , 2001, Evidence report/technology assessment.

[40]  Gary P. Pisano,et al.  Organizational Differences in Rates of Learning: Evidence from the Adoption of Minimally Invasive Cardiac Surgery , 2001, Manag. Sci..

[41]  E J Orav,et al.  Negligent care and malpractice claiming behavior in Utah and Colorado. , 2000, Medical care.

[42]  M. Choti,et al.  Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. , 1999, Annals of surgery.

[43]  F W Cheney,et al.  The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future? , 1999 .

[44]  A. Gawande,et al.  The incidence and nature of surgical adverse events in Colorado and Utah in 1992. , 1999, Surgery.

[45]  A. Renehan,et al.  Surgeon-related factors and outcome in rectal cancer. , 1999, Annals of surgery.

[46]  C. Begg,et al.  Impact of hospital volume on operative mortality for major cancer surgery. , 1998, JAMA.

[47]  N. Powe,et al.  The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. , 1998, Annals of surgery.

[48]  K. Hammermeister,et al.  Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. , 1998, Journal of the American College of Surgeons.

[49]  F. Grover,et al.  Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. , 1997, Journal of the American College of Surgeons.

[50]  A. Re.  Outcomes of medical-malpractice litigation. , 1997 .

[51]  T A Brennan,et al.  Relation between negligent adverse events and the outcomes of medical-malpractice litigation. , 1996, The New England journal of medicine.

[52]  Russell L. Stogsdill,et al.  A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. , 1996, JAMA.

[53]  J. Lynch,et al.  Outcome analysis of carotid endarterectomy in Connecticut: The impact of volume and specialty , 1996, Annals of vascular surgery.

[54]  Marilyn Sue Bogner,et al.  Human Error in Medicine , 1995 .

[55]  Robert L. Helmreich,et al.  Team performance in the operating room. , 1994 .

[56]  T. Brennan,et al.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. , 1991, The New England journal of medicine.

[57]  S. Zeger,et al.  Longitudinal data analysis using generalized linear models , 1986 .

[58]  D. Fry.  Reoperative surgery of the abdomen , 1986 .

[59]  A. Enthoven,et al.  Should operations be regionalized? The empirical relation between surgical volume and mortality. , 1980, The New England journal of medicine.