Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.

摘要

Surgically trained reviewers analyzed 444 randomly sampled surgical malpractice claims from 4 liability insurers. Among 258 claims in which injuries due to error were detected, 52% (N - 133) resulted from technical error. Evaluation of compiled data demonstrates that 49% of technical errors caused permanent disability, and 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 (16%); surgeons inexperienced with the task (14%), " of poorly supervised residents (9%). The majority involved experienced surgeons (73%) and occurred in "routine" operations (84%). Patient- or event-related factors, such as' emergencies and difficult or unexpected anatomy, contributed to 61% of technical errors, and technology or systems failures played a significant role in 21%.