Preoperative | 127 (32.8) |
Cancer
Failure to review preoperative imaging leading to only partial removal of tumour and delayed diagnosis of invasive bladder cancer. Failure to appreciate patient’s changing symptoms between initial diagnosis of lipoma and surgery, resulting in failure to perform a biopsy preoperatively, leading to delayed diagnosis of leiomyosarcoma.
| 29 (22.8) |
Gastrointestinal disease
| 17 (13.4) |
Musculoskeletal and connective tissue disease
Wrong interpretation of imaging, thus incorrectly diagnosing patellofemoral pain syndrome as subluxation. Failure to appreciate progressing symptoms of cauda equina syndrome while patient in hospital awaiting surgery, resulting in failure to expedite surgery. This left the patient with permanent neurologic deficits.
| 14 (11.0) |
Genitourinary disease
Failure to perform imaging before surgery to confirm the absence of kidney stones, resulting in unnecessary surgery that was complicated by ureteric avulsion. Wrong diagnosis of left-sided kidney stone due to failure to read radiology report that confirmed right-sided kidney stone, and instead relying on referral request, resulting in wrong-sided surgery.
| 12 (9.4) |
Intraoperative | 120 (31.0) |
Injury during surgery
Failure to perform a rectal or vaginal exam after colposacropexy with mesh led to missed diagnosis of suture in rectum with subsequent suture erosion, resulting in rectovaginal fistula. Failure to investigate source of bile contamination intraoperatively resulted in missed diagnosis of laceration to jejunum.
| 25 (20.8) |
Misidentification of anatomy
Failure to obtain a laparoscopic critical view of safety led to the clipping and transection of the common bile duct rather than the cystic duct and cystic artery. This resulted in a missed diagnosis of intraoperative common bile duct injury. Failure to identify the superior mesenteric artery resulted in a missed diagnosis of arterial injury and subsequent complete bowel ischemia.
| 21 (17.5) |
Retained foreign body
| 19 (15.8) |
Postoperative | 171 (44.2) |
Complications of surgical injury, including failure to recognize subsequent clinical deterioration
| 62 (36.3) |
Gastrointestinal complications
Failure to appreciate persistence of tachycardia, increased leukocyte count, and abdominal pain on postoperative day 8 resulted in delayed diagnosis of bowel perforation. Delayed diagnosis of gastric necrosis and subsequent failure to expedite surgery once diagnosis confirmed.
| 21 (12.3) |
Progression or persistence of cancer
Surgeon failed to appreciate need for postoperative follow-up for patient with preoperative breast biopsy that showed high-grade ductal carcinoma in situ with one focus highly suspicious for microinvasion and a postoperative lumpectomy negative for cancer, despite pathologist recommending close follow-up. Patient subsequently developed ductal carcinoma. Failure to order follow-up imaging 6–12 months after surgery resulted in delayed diagnosis of metastatic spread.
| 18 (10.5) |
Genitourinary complications
Delay in diagnosis of ureteric injury when patient presented postoperatively with elevated creatinine, dilated ureter, and hydronephrosis, resulting in perforation of distal ureter and urinoma. Failure to recognize priapism as an adverse effect of trazodone that was prescribed postoperatively and arrange a timely referral to a urologist.
| 17 (9.9) |
Musculoskeletal and connective tissue complications
Failed to confirm on postoperative imaging that fracture was in good alignment, resulting in delayed diagnosis of fracture displacement. Failed to obtain postoperative imaging before and after hardware removal to confirm healing, resulting in delayed diagnosis of fracture non-union and subsequent joint deformity.
| 15 (8.8) |
Other postoperative complications
| 16 (9.4) |