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Failure Analysis at a High-Volume Academic Medical Center

Robert R. Cima, MD, MA; Curt Hale, BS; Anantha Kollengode, PhD, MBA; James C. Rogers, PMP; Stephen D. Cassivi, MD, MSc; Claude Deschamps, MD

Arch Surg. 2010;145(7):641-646.

Hypothesis  Describe the incidence, type, and detection method of surgical listing errors and implement a system to reduce errors.

Design  All errors/discrepancies between the surgical listing and the performed procedure reported to an institutional event line during 2008 were analyzed.

Setting  Academic tertiary medical center.

Main Outcome Measures  Error characteristics and detection mode were documented. An error causal tree analysis was developed and used to modify the standard listing process to reduce errors.

Results  During 2008, 759 listing errors were reported of 55 197 surgical procedures for an error rate of 1.38%. No wrong-site surgeries occurred. The errors were missing laterality (501; 66%), incorrect side (108; 14%), incorrect listing besides laterality (86; 11%), and other (64; 9%). Identification/correction of the listing error occurred in the following areas: nursing review the evening prior to surgery (517; 68%), preoperative admission unit (132; 17%), operating room (98; 12%), recovery room (6; 0.8%), and other (6; 0.8%). Using a causal tree analysis, error-proofing strategies applied in an electronic standardized case listing system significantly reduced the error rate from 1.50% to 0.54% (P < .05) and 2.06% to 0.49% (P < .05) in gynecologic and colorectal surgery, respectively.

Conclusions  Surgical listings errors occur with a low constant rate across specialties. The majorities of errors were related to laterality and were detected prior to surgery. An electronic listing system using standardized case descriptions with required laterality significantly reduced the error frequency.

Author Affiliations: Department of Surgery (Drs Cima, Cassivi, and Deschamps), Systems and Procedures (Mr Rogers), Quality Management Services (Mr Hale and Dr Kollengode), and Surgical Quality Assessment Committee (Drs Cima, Kollengode, and Cassivi and Messrs Hale and Rogers), Mayo Clinic, Rochester, Minnesota.

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