How Often Do Catastrophic Surgery Mistakes Really Happen?

A new meta-analysis of 138 previous studies finds different rates for different mistakes.
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(Photo: Dario Lo Presti/Shutterstock)

(Photo: Dario Lo Presti/Shutterstock)

Last week, we wrote about a study that looked at why surgeons sometimes make catastrophic mistakes. (Think: operating on the wrong body part, or leaving a surgical tool behind in the patient's body.) The study found that doctors and nurses are cognitively overworked and need help lightening the load. Now, another new paper adds more detail to the emerging picture of these awful, yet preventable mistakes. In an analysis of 138 previously published papers on worst-case-scenario surgery errors, a team of researchers from the RAND Corporation, University of California-Los Angeles, and the United States Department of Veterans Affairs found:

  • Surgeries that happen in the wrong part of the body—such as a right leg versus a left leg—occur at a rate of about one per 100,000 surgeries. But individual estimates vary widely.
  • About one in every 7,600 surgeries results in something being left behind in the human body. The most common items forgotten in someone's insides: surgical sponges.
  • Miscommunication is a commonly reported reason for catastrophic surgery mistakes. Last week's study cited communication troubles as a major problem category, too.
  • Most mistake-prevention programs have only so-so supporting science. Studies often don't find statistically significant improvements in mistake rates after prevention programs. That doesn't mean surgery-safety programs are useless, according to the authors of the new study, out today in the journal JAMA Surgery. Most safety programs are designed in part to prevent more commonplace problems—such as infections or even death after surgery—which aren't considered to be in the same category as, say, operating on the wrong body part. Medical jargon calls that latter type of mistake "never events," because they should never happen. But several studies have found that prevention programs actually do work to lessen the likelihood of those less dumbfounding mistakes.

In addition, it can take an overwhelming amount of data to find statistically significant results for these unusual blunders. Although they ought to be rarer, surgery "never events" are already infrequent enough that it may be difficult for researchers to gather enough data to prove a prevention program's effectiveness. Think of it this way: If a prevention program reduces the rate of a mistake from one in 20,000 to one in 30,000, mathematically, you would need five million data points to detect that difference. One way to overcome this problem is for researchers from different institutions to cooperate and combine their data.

The bottom line? Preventable, grave surgery mistakes are pretty rare, although not rare enough. The JAMA Surgery researchers calculated their numbers work out to 500 Americans having surgery in the wrong area of the body per year, and—crazier yet—5,000 people having an object stitched up inside them. Figuring out what works to prevent these problems will take lots more data.

Quick Studies is an award-winning series that sheds light on new research and discoveries that change the way we look at the world.

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