Table 3

Contributing factors of surgical diagnostic error cases by provider, team, and system

Contributing factor*No. (%) of cases
n = 387
Provider317 (81.9)
 Clinical decision-making (e.g., deficient assessment, failure to perform test or intervention, misinterpretation of a test result, failure to refer)150 (47.3)
 Failure to follow up on a complication85 (26.8)
 Loss of situational awareness (e.g., inadequate monitoring or follow-up, insufficient knowledge or skill, failure to review medical record, premature discharge)74 (23.3)
 Inadequate evaluation of a presenting condition or comorbidity53 (16.7)
 Procedural violations (e.g., deviation from clinical practice guideline, deviation in use of equipment, deviation from administrative procedure)32 (10.1)
Team194 (50.1)
 Communication breakdown with the patient (e.g., inadequate consent process, inadequate communication at discharge, inadequate disclosure of error)117 (60.3)
 Documentation issues105 (54.1)
 Communication breakdown between physicians (e.g., inadequate handover of care)22/ (11.3)
 Communication breakdown with nonphysician providers17 (8.8)
 Coordination of care issues between physicians (e.g., breakdown in consultation process)12 (6.2)
System46 (11.9)
 Resource issues (e.g., malfunctioning equipment, insufficient or unavailable resource, wait time issue)21 (45.7)
 Protocol, policy and procedure issues (e.g., inadequate facility administrative procedure, test result mix-up)18 (39.1)
 Office issues (e.g., health information technology issue)11 (23.9)
  • * Some cases had more than 1 contributing factor; therefore, the sum of frequencies does not equal 100%.

  • Frequency of contributing factor presented as a proportion of factor domain (provider, team or system).