Factors contributing to intraoperative injuries based on peer expert opinion in legal cases with criticism of care
| Contributing factor | No. (%) of cases* | ||
|---|---|---|---|
| All cases n = 134 | Nongynecologic n = 95 | Gynecologic n = 39 | |
| Provider clinical care | 110 (82.1) | 80 (84.2) | 30 (76.9) |
| Clinical evaluation and decision-making | 58 (43.3) | 44 (46.3) | 14 (35.9) |
| Deficient knowledge, skill or technique | 53 (39.6) | 41 (43.2) | 12 (30.8) |
| Misidentification of anatomy | 37 (27.6) | 34 (35.8) | 3 (7.7) |
| Delayed recognition of injury | 28 (20.9) | 21 (22.1) | 7 (17.9) |
| Procedural violation | 27 (20.1) | 16 (16.8) | 11 (28.2) |
| Team communication factors | 62 (46.3) | 45 (47.4) | 17 (43.6) |
| Informed consent | 40 (29.9) | 28 (29.5) | 12 (30.8) |
| Documentation | 33 (24.6) | 26 (27.4) | 7 (17.9) |
| System factors | 15 (11.2) | 11 (11.6) | 4 (10.3) |
| Equipment or resource issues | 9 (6.7) | 7 (7.4) | 2 (5.1) |
| Administrative protocols | 8 (6.0) | 6 (6.3) | 2 (5.1) |
↵* Some cases had more than 1 contributing factor.