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Analysis of surgical errors in closed malpractice claims at 4 liability insurers.
Surgery. 2006 Jul; 140(1):25-33.S

Abstract

BACKGROUND

The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention.

METHODS

We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded.

RESULTS

Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001).

CONCLUSIONS

Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors.

Authors+Show Affiliations

Brigham and Women's Hospital, Boston, Mass; Brigham and Women's Hospital and Center for Surgery and Public Health, Boston, Mass, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

16857439

Citation

Rogers, Selwyn O., et al. "Analysis of Surgical Errors in Closed Malpractice Claims at 4 Liability Insurers." Surgery, vol. 140, no. 1, 2006, pp. 25-33.
Rogers SO, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25-33.
Rogers, S. O., Gawande, A. A., Kwaan, M., Puopolo, A. L., Yoon, C., Brennan, T. A., & Studdert, D. M. (2006). Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery, 140(1), 25-33.
Rogers SO, et al. Analysis of Surgical Errors in Closed Malpractice Claims at 4 Liability Insurers. Surgery. 2006;140(1):25-33. PubMed PMID: 16857439.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Analysis of surgical errors in closed malpractice claims at 4 liability insurers. AU - Rogers,Selwyn O,Jr AU - Gawande,Atul A, AU - Kwaan,Mary, AU - Puopolo,Ann Louise, AU - Yoon,Catherine, AU - Brennan,Troyen A, AU - Studdert,David M, PY - 2005/10/30/received PY - 2006/01/19/revised PY - 2006/01/20/accepted PY - 2006/7/22/pubmed PY - 2006/8/22/medline PY - 2006/7/22/entrez SP - 25 EP - 33 JF - Surgery JO - Surgery VL - 140 IS - 1 N2 - BACKGROUND: The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention. METHODS: We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded. RESULTS: Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001). CONCLUSIONS: Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors. SN - 0039-6060 UR - https://www.unboundmedicine.com/medline/citation/16857439/Analysis_of_surgical_errors_in_closed_malpractice_claims_at_4_liability_insurers_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0039-6060(06)00058-4 DB - PRIME DP - Unbound Medicine ER -