Surgical error comes in many varieties but is almost never a single isolated slip, at least when serious injury happens to the patient. As a leading study on medical malpractice claims and surgical errors found, the errors that caused serious harm tended to involve multiple failures by multiple individuals at multiple phases of care.
We have much more information about specific types of surgical errors and specific types of injuries that these errors cause in the linked pages at the end of this entry.
The surgeon also usually is in charge of the post-surgery follow-up to make sure the patient survives and goes home in good shape. This usually requires the surgeon to visit the patient every day until discharge.
And back to square one: The decision of whether a patient really needs surgery, and what kind should be done, is also usually delegated to the surgeon. So many malpractice issues of misdiagnosis also fit under the topic of surgical error.
Thus, surgery is a complex enterprise that requires good coordination of teams of care providers.
As the study on malpractice claims reported:
Our study reveals that, although patient harm from isolated individual errors occurs, the vast majority of surgical error cases involve multiple layers of failure. Of 258 cases analyzed, most involved more than 1 clinician, and nearly one third involved chains of events crossing multiple phases of care. In 68%, 1 or more of the following 4systems factors contributed to error: communication breakdowns, lack of supervision, technology failures, and patient-related factors. In addition, a surgeon’s lack of experience or technical competence (which can be understood as having both individual and systems components) was a contributing factor in 41% of cases. Individual errors in judgment, vigilance, or memory were certainly not irrelevant. On the contrary, 9 of 10 cases involved at least 1 of these cognitive errors. In more than 80% of cases, however, they acted in concert with other factors in producing harm. This finding was true even among those surgical errors, which, at a superficial level, appeared to be purely technical in nature.
Selwyn Rogers and others, “Analysis of surgical errors in closed malpractice claims at 4 liability insurers,” (Surgery 2006;140:25-33.)
See Also: Our web pages on specific types of surgery:
- Back surgery
- Cosmetic surgery
- Laparoscopic surgery errors
- LASIK surgery
- Orthopedic Surgery
- Weight loss surgery
See Also: Our web pages on specific surgical errors:
- Amputation injuries
- Bile duct injury
- Blood clot mismanagement
- Brachial plexus injury
- Cauda equina syndrome
- Esophageal perforation
- Intestinal obstruction
- Nerve damage after surgery
- Pulmonary Embolism
- Spinal abscess
- Spinal hematoma
- Surgical fires
- Unnecessary surgery
- Wrong site surgery/ wrong procedure/ wrong patient surgery
Patient Safety Tip: Finding the Right Surgeon
Experience with the exact type of surgery you are about to undergo is critical to a good outcome. So that makes the patient’s job very straight-forward: You MUST ask the question: “What is your experience with this procedure?” But there’s a lot more to ask as well. Read more…
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