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The origins of malpractice claims.

Studies implying that patients undergoing complex surgical operations fare better when those operations are done in high-volume centers by experienced surgeons brought smug nods of knowing assent among my peers. After all, such observations made sense and were congruent with our own observations and sense of competency. The authors of “Patterns of Technical Error Among Surgical Malpractice Claims: An Analysis of Strategies to Prevent Injury to Surgical Patients” published in this issue ask the reverse question: Do better outcomes for patients treated in high-volume centers by highly experienced surgeons mean that most surgical error is committed by inexperienced surgeons? Given the fact that one-half to two-thirds of all hospital adverse events are attributable to surgical care, this question is of vital importance to every individual licensed to use a sharp object in the care of another human being. The answer that Regenbogen et al propose is at once surprising and not a surprise at all. The authors use closed malpractice claims data, a powerful tool for detecting when bad outcomes have occurred and lawsuits have ensued. The data are collected from 3 regions of the United States and 4 malpractice insurance companies. In a way, this is looking at surgical error from the other end of the telescope. Rather than observational studies of near misses, chart reviews, or “root cause analyses” (which are often not RCAs in the aviation sense), this study examines an ultimate consequence of adverse event due to error: a malpractice claim. There are several limitations to such a study, most of which are readily acknowledged by the authors. Malpractice claims are rich in the detection of adverse outcome as a consequence of error (highly specific, in a sense), but they lack sensitivity because many adverse events caused by error do not come to legal action. For instance, in this study 58% of claims were due to error. Yet, in other studies of randomly selected discharges, as many as 97% of adverse events due to error did not lead to a claim. Claims data will detect error frequently, but they will not detect most errors or even most adverse events due to error. Nonetheless, adverse events due to error detected in this way are a rich source for examination. Who is making the mistakes and under what circumstances? The surprising or not surprising answer is that most technical errors occur in routine operations preformed by experienced surgeons. The associated observation is that there are often confounding conditions contributing to these errors, such as patient complexity (difficult anatomy, previous operation, or emergency) (61%), or systems or human factors failures (21%). It is not the neophyte doing a 10-hour Whipple that leads to the most malpractice claims; it is the experienced general surgeon doing a gastrectomy on a patient with 3 previous upper abdominal operations and a replaced left hepatic artery. What the authors do not know is the incidence of such events. It stands to reason that experienced surgeons will do more common operations more frequently than index cases (like that Whipple); thus, the exposure is greater in the more commonly performed procedures. Most automobile accidents occur close to home because your car is more frequently coming from or going to your house than it is making the 6-hour drive to your favorite vacation spot. There is a lot we do not know. Are less experienced surgeons less busy, thereby less exposed to risk? Less experienced surgeons were more likely to have equipment problems in