Analysis of surgical errors in closed
malpractice claims at 4 liability
insurers
Selwyn O. Rogers, Jr, MD, MPH,
a,b
Atul A. Gawande, MD, MPH,
a,b
Mary Kwaan, MD,
a
Ann Louise Puopolo, BSN, RN,
c
Catherine Yoon, MS,
a
Troyen A. Brennan, MD, JD, MPH,
a,d
and
David M. Studdert, LLB, ScD, MPH,
d
Boston, Mass
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.
(Surgery 2006;140:25-33.)
From the Brigham and Women’s Hospital,
a
and Brigham and Women’s Hospital and Center for Surgery and
Public Health
b
; the Harvard Risk Management Foundation
c
; and the Harvard School of Public Health
d
Reducing the incidence and cost of medical
injuries has become a national health care priority
in the United States. Estimates from previous pa-
tient safety research suggest that one half to two
thirds of inpatient adverse events are attributable to
surgical care,
1-3
and that more than half of these
events may be preventable.
3,4
However, prevention
efforts depend on detailed knowledge of the etiol-
ogy of errors in surgery, which remains meager.
Researchers have linked poor surgical outcomes
to a wide variety of factors, including surgeon in-
experience,
5-7
low hospital volume for some oper-
ations,
8-14
excessive workload,
15
fatigue,
16,17
lack of
optimal technology,
18
poor supervision of train-
ees,
19
inadequate hospital systems,
20
poor staff
communication,
21
emergency circumstances,
22
and
time of day.
23
Many of these are “systems” factors—
that is, they involve interrelationships between in-
dividuals, their tools, and the environment they
work in, rather than single straightforward causes.
However, determining the relative importance of
these causal factors in surgical errors to target
interventions has proved extremely difficult.
Supported by grant HS011886-03 from the Agency for Health-
care Research and Quality and the Harvard Risk Management
Foundation. Dr Studdert also was supported by grant
KO2HS11285 from the Agency for Healthcare Research and
Quality.
Accepted for publication January 20, 2006.
Reprint requests: Dr Studdert, Harvard School of Public Health,
677 Huntington Ave, Boston, MA 02115. E-mail: studdert@
hsph.harvard.edu
0039-6060/$ - see front matter
© 2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.surg.2006.01.008
SURGERY 25