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

Scott E. Regenbogen, MD, MPH; Caprice C. Greenberg, MD, MPH; David M. Studdert, LLB, ScD, MPH; Stuart R. Lipsitz, ScD; Michael J. Zinner, MD; Atul A. Gawande, MD, MPH


Annals of Surgery. 2007;246(5):705-711. 

In This Article


Characteristics of Cases and Errors

Among the 133 study cases, we identified 140 discrete technical errors (range 1-2 per case; Fig. 1). Characteristics of the errors are displayed in Table 1 . Attending surgeons were responsible for 97 (69%) of the errors, and another 38 (27%) involved both attending physicians and trainees. Only 5 errors (4%) were attributed to surgical residents or fellows alone. The most common types of operations associated with the errors were general or gastrointestinal surgery (31%), spine surgery (15%), gynecologic surgery (12%), and nonspine orthopedic surgery (9%).

Most of the technical errors caused serious injury to patients. Forty-nine percent resulted in permanent disability (68 of 140), and an additional 16% resulted in death (22 of 140).

Ninety-one percent of the technical errors involved manual error and 35% involved judgment or knowledge error ( Table 2 ). Nearly two-thirds (65%) of the technical errors involved manual error only; 26% had both manual and judgment or knowledge components; few involved solely knowledge or judgment errors (9%).

The specific types of errors are arrayed in Table 2 . The most common type of manual error involved incidental visceral injury (34%), followed by breakdown of operative repair or failure to relieve the disease (16%), hemorrhage (16%), and peripheral nerve injury (14%). The most common type of judgment or knowledge error was delay or error in intraoperative diagnosis or management (16%), which often consisted of failure to recognize an intraoperative complication. Other relatively frequent judgment or knowledge errors included incorrect choice of procedure or technique (9%) and wrong operative site (7%).

Operative Complexity and Surgeon Experience Level

A minority of the technical errors involved index operations (16%), inexperienced surgeons (8%), surgeons operating outside their area of expertise (5%), or unexpected events that required skills outside a surgeon's area of expertise (1%) (Fig. 2). Eighteen failures (13%) were attributed to surgical trainees, but only 13 (9%) occurred in the absence of adequate supervision by an attending surgeon.

Figure 2.

Surgeon experience level in 140 technical errors among index operations (advanced procedures requiring special training) versus routine operations. Index operations are high-complexity, subspecialty procedures for which additional training and specialization beyond a standard residency and/or fellowship is usually required. All other operations are considered routine. Surgeons' experience level was ascertained from their number of years in practice, specialty training, and volume of experience with the specific procedure.

A majority (84%) of the technical errors involved routine operations, and 73% involved experienced surgeons operating within their area of expertise and training. When stratified by complexity of the operation, experienced surgeons accounted for 68% of technical errors among index operations and 74% of errors among routine operations. This difference was not statistically significant (P = 0.59).

Contributing Factors in Technical Errors

Overall, 69% of technical errors involved complicating factors ( Table 3 ), related either to the patient (61%) or to human or systems factors (21%). The leading patient-related complexities were difficult or unusual anatomy (25%), reoperation (20%), and urgent or emergency operations (17%). Equipment-use problems (16%) accounted for the majority of human or systems factors.

These complicating factors occurred with equal frequency among technical errors at the hands of experienced surgeons and those at the hands of inexperienced surgeons or trainees (69% vs. 71%; P = 0.78). Experienced surgeons' technical errors were significantly more likely to involve difficulties because of repeat operations (25% vs. 8%; P = 0.03) and were significantly less likely to involve equipment-use problems (12% vs. 29%; P = 0.01). Otherwise, there were no significant differences in the distribution of contributing factors.

Interrater Reliability Measures

The kappa statistics measuring interrater reliability of the secondary reviewers' judgments on contributing factors ranged from 0.69 to 0.98, indicating very good to excellent overall agreement.[46]


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