Contributing factors of surgical diagnostic error cases by provider, team, and system
| Contributing factor* | No. (%) of cases† n = 387 |
|---|---|
| Provider | 317 (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 complication | 85 (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 comorbidity | 53 (16.7) |
| Procedural violations (e.g., deviation from clinical practice guideline, deviation in use of equipment, deviation from administrative procedure) | 32 (10.1) |
| Team | 194 (50.1) |
| Communication breakdown with the patient (e.g., inadequate consent process, inadequate communication at discharge, inadequate disclosure of error) | 117 (60.3) |
| Documentation issues | 105 (54.1) |
| Communication breakdown between physicians (e.g., inadequate handover of care) | 22/ (11.3) |
| Communication breakdown with nonphysician providers | 17 (8.8) |
| Coordination of care issues between physicians (e.g., breakdown in consultation process) | 12 (6.2) |
| System | 46 (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) |