Patterns of Technical Error Among Surgical Malpractice Claims
Patterns of Technical Error Among Surgical Malpractice Claims
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.
The morbidity and cost of medical injuries have inspired broad interest in strategies to reduce preventable adverse events. Research showing that between one-half and two-thirds of hospital adverse events are attributable to surgical care has brought the need for safety interventions in surgery to the forefront. The design and success of such efforts, however, depend on improving our understanding of the etiology of surgical error.
The causes of error in medical care may not be easily generalized to surgery because these specialties differ in important ways. In particular, most surgical errors occur in the operating room and are technical in nature. Technical errors are defined to include direct manual errors (such as transection of the ureter during hysterectomy) as well as judgment and knowledge errors leading to performance of an inappropriate, inadequate, or untimely procedure (for example, performing simple cholecystectomy for invasive adenocarcinoma of the gallbladder, or failing to intervene promptly in a patient with a leaking aortic aneurysm). They can occur in any phase of care, and are pervasive in surgery.
The key causes of technical error in surgery remain poorly understood, although a number of factors have been identified. Surgical complications and adverse outcomes have been linked to lack of surgeon specialization, low hospital volume, communication breakdowns, fatigue, surgical residents and trainees, and numerous other factors. Research linking surgical volume to patient outcomes in high-complexity operations implies that low-volume surgeons or younger, inexperienced surgeons are an important source of error. The importance of risk adjustment in comparisons of postoperative mortality rates suggests that patients' comorbidities and operative complexity are key factors.
Each of these factors leads to hypotheses about the causes of surgical error, and suggest a variety of specific interventions, such as mentoring, consultation, and extended training for young surgeons, selective referral to high-volume providers, restrictions on privileging for high-complexity operations, or development of specific risk-reduction strategies for high-risk circumstances. Prioritization, however, depends on understanding which contributing factors are most important, and this has remained unknown for several reasons. Studies of surgical complications using administrative data have lacked sufficient clinical detail, and chart reviews, observational studies, and root cause analyses have proved too time- and labor-intensive to replicate on a large scale.
To date, closed malpractice claims have been rarely used because of concerns about confidentiality, unfounded litigation, and generalizability. Yet, this data source offers a very broad catchment point for studying serious injuries, and the claim records supply detailed clinical and contextual information about the care provided. In this study, we used a large national database of surgical malpractice claims to identify and analyze a set of technical errors that resulted in serious injury to surgical patients.
Abstract and Introduction
Abstract
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.
Introduction
The morbidity and cost of medical injuries have inspired broad interest in strategies to reduce preventable adverse events. Research showing that between one-half and two-thirds of hospital adverse events are attributable to surgical care has brought the need for safety interventions in surgery to the forefront. The design and success of such efforts, however, depend on improving our understanding of the etiology of surgical error.
The causes of error in medical care may not be easily generalized to surgery because these specialties differ in important ways. In particular, most surgical errors occur in the operating room and are technical in nature. Technical errors are defined to include direct manual errors (such as transection of the ureter during hysterectomy) as well as judgment and knowledge errors leading to performance of an inappropriate, inadequate, or untimely procedure (for example, performing simple cholecystectomy for invasive adenocarcinoma of the gallbladder, or failing to intervene promptly in a patient with a leaking aortic aneurysm). They can occur in any phase of care, and are pervasive in surgery.
The key causes of technical error in surgery remain poorly understood, although a number of factors have been identified. Surgical complications and adverse outcomes have been linked to lack of surgeon specialization, low hospital volume, communication breakdowns, fatigue, surgical residents and trainees, and numerous other factors. Research linking surgical volume to patient outcomes in high-complexity operations implies that low-volume surgeons or younger, inexperienced surgeons are an important source of error. The importance of risk adjustment in comparisons of postoperative mortality rates suggests that patients' comorbidities and operative complexity are key factors.
Each of these factors leads to hypotheses about the causes of surgical error, and suggest a variety of specific interventions, such as mentoring, consultation, and extended training for young surgeons, selective referral to high-volume providers, restrictions on privileging for high-complexity operations, or development of specific risk-reduction strategies for high-risk circumstances. Prioritization, however, depends on understanding which contributing factors are most important, and this has remained unknown for several reasons. Studies of surgical complications using administrative data have lacked sufficient clinical detail, and chart reviews, observational studies, and root cause analyses have proved too time- and labor-intensive to replicate on a large scale.
To date, closed malpractice claims have been rarely used because of concerns about confidentiality, unfounded litigation, and generalizability. Yet, this data source offers a very broad catchment point for studying serious injuries, and the claim records supply detailed clinical and contextual information about the care provided. In this study, we used a large national database of surgical malpractice claims to identify and analyze a set of technical errors that resulted in serious injury to surgical patients.
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