Table 2

Diagnosis by surgical phase of care with examples of diagnostic errors

Surgical phase of care and diagnosisNo. (%) of cases*
n = 387
Preoperative127 (32.8)
  • 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
  • Surgery performed for suspected cancer recurrence without awaiting preoperative pathology findings that identified scar tissue. This led to unnecessary surgery performed on a high-risk patient, ultimately resulting in their death.

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)
Intraoperative120 (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
  • Failure to perform a final sweep of the abdomen looking for sponges and ensure the count was correct before closing resulted in a missed diagnosis of retained surgical sponge.

19 (15.8)
Postoperative171 (44.2)
Complications of surgical injury, including failure to recognize subsequent clinical deterioration
  • Failure to appreciate patient’s ongoing hypotension and tachycardia postoperatively led to delayed imaging and delayed diagnosis of perforation of uterus and sigmoid colon, resulting in septic shock.

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
  • Delay in notifying final blood culture result for postoperative infection to patient or their family physician, resulting in treatment with the wrong antibiotics for 7 months and unnecessary surgeries and dressing changes.

16 (9.4)
  • * Frequency of diagnosis presented as a proportion of surgical phase.