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Errors in the Surgical Setting

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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Friday, October 18, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

CEUFast, Inc. (BOC AP#: P10067) is approved by the Board of Certification, Inc. to provide education to Athletic Trainers (ATs).

≥92% of participants will understand the etiology of surgical errors and ways to prevent them.


After completing this continuing education course, the participants will be able to meet the following objectives:

  1. Define the term "never events."
  2. Identify which updated term has replaced "never events" in the medical literature.
  3. Identify the components of wrong-site surgeries.
  4. Describe the purpose of the National Time Out Day.
  5. Describe how a surgical site should be marked.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Errors in the Surgical Setting
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
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Author:    Berthina Coleman (MD, BSN,RN)


Since the publication of the benchmark "To Err is Human" from the Institute of Medicine in 1998, healthcare institutions have mostly moved toward emphasizing safety and quality of care in medicine. Since the report's publication, several patient safety initiatives have been implemented with overall improved hospital standards (Marsh et al., 2022).

In 2001, the National Quality Forum's chief executive officer coined the term "never event" to identify flagrant medical errors that should never occur. An example of a "never event" includes a wrong surgery site procedure. However, the term "never event" has since been replaced by the term "serious reportable events" (Ritsema et al., 2021). In 2019, the National Quality Forum published a list of "serious reportable events" that were classified into several categories, namely:

  • Surgical invasive procedures
  • Product or device
  • Patient protection
  • Care management
  • Environmental
  • Radiologic
  • Potentially criminal events

The reportable events related to the surgical field include:

  • Surgery performed on the wrong site
  • Surgery performed on the wrong patient
  • The incorrect surgical procedure performed on a patient
  • Unintentional retention of a foreign body in a patient after surgery
  • Intraoperative or immediate postoperative death in an average healthy patient


Adverse Events

An adverse event is an injury caused by medical management rather than the underlying disease. Adverse events can lead to prolonged hospitalization or disability. However, some of these adverse events may be preventable (Cohen et al., 2021).


Errors occur when the planned activity fails to achieve its intended outcome, and these failures cannot be ascribed to chance. Note that an adverse event can occur without an error, an error can occur without an adverse event, and an error can cause an adverse event (Cohen et al., 2021).

Wrong-site Surgeries

Wrong-site surgeries include several components: procedures involving the wrong site, wrong side, wrong patient, or wrong procedure performed (AORN, 2022). According to the Association of Perioperative Nurses, the establishment of the National Time Out Day is helpful. It raises awareness about how the time-out process creates an opportunity for nurses to speak up for their patients and perioperative team members to review processes that may contribute to wrong-site surgeries (AORN, 2022). Approximately 1 in every 100,000 cases represents a wrong-site surgery. The incidence may be as high as 4.5 every 10,000 cases, depending on the procedure performed (Geraghty et al., 2020).

Universal Protocol for Preventing Wrong-Surgery Type Errors

In 2004, the Joint Commission established a patient safety mandate named the "Universal Protocol" for preventing wrong-site, wrong-procedure, or wrong-person surgery. There are three main steps to the "Universal protocol," which should be performed every single time, and the expectation is that all members of the team must participate in the process as appropriate.

Step 1: Preoperative Verification

Preoperative verification involves verifying the patient's identity, the correct procedure, and the site of the intended procedure. The process begins when the procedure is scheduled, confirmed upon admission, and again any time care is transferred. For example, at the time of transfer from the preoperative setting to the operating room.

Step 2: Marking of the Surgical Site

The operative site should be marked using a permanent marker to remain visible after the surgical prep procedure. Ideally, the mark should be made using a surgical line, or word instead of the letter "X." Marking of the surgical site should be done by a surgical team member, ideally, by the primary surgeon. Patients should be encouraged to participate in the site marking process when clinically feasible. Note that some sites are not amenable to being marked, for example, the tonsils. In those cases, the procedure should be confirmed with the surgeon, the clinical team, and the patient (if possible).

Step 3: Time-out

The time-out procedure starts just before the surgery. The time-out procedure must be performed where the surgical procedure is being performed, usually in the operating room. All surgical team members must participate in the time-out process, including the surgeon, nurses, and anesthesia team. The time-out procedure must take place before the incision is made. One of the reasons for the success of the surgical checklist implementation is based on the associated improved communication between team members. The checklist is extremely useful because most clinical errors, including wrong-site surgery, have resulted from poor communication between team members.

Other Types of Errors in the Surgical Setting

Errors in Surgical Specimen Handling

Errors in surgical specimen handling can increase the risk of patient harm by causing treatment delays, missed diagnosis, or selection of the incorrect therapy. Although surgical specimen collection occurs daily in multiple hospitals, it is still a multi-step process that involves collecting and transporting the specimen and pathologic analysis (Holstine and Samora, 2021).

Several factors can cause errors in the handling of surgical specimens, including the lack of ownership of the specimen, unclear communication, and a complicated electronic medical record system. Most errors occur before the pathology analysis. The most common error is the mixing of specimens between two patients. Other common errors include mislabeled specimens or lost specimens. Note that the cost of surgical specimen errors can be very high (Holstine and Samora, 2021).

Errors in Diagnosis

Errors in diagnosis occur when the pathology report contradicts the preoperative diagnosis. It can also occur when the intraoperative findings do not match the preoperative results. Other diagnosis errors include failure to recognize adverse events and incorrectly interpreting signs and symptoms. An example of an error in diagnosis includes a patient who is diagnosed with sigmoid diverticulosis and undergoes an intra-abdominal laparotomy, which is negative for acute pathology. A few days post-op, the patient becomes septic and eventually dies secondary to pulmonary septic emboli with a large saddle embolus (Ritsema et al., 2022).

Errors in Judgment

Errors in judgment can happen when deciding whether or not a patient should be taken into the operating room. It is essential to carefully weigh the risk-benefit ratio of every proposed treatment or procedure. Errors in judgment can also occur in the intraoperative setting leading the surgeon to do the wrong procedure, be too aggressive in their approach, or not be aggressive enough during the procedure. Proceeding with a surgical procedure on an unstable patient in the intraoperative setting is an example of a judgment error.

Errors in Technique

Errors in technique include unintentional damage to organs or other structures adjacent to the surgical site. Examples include intraabdominal ischemia or a surgical leak secondary to poor surgical technique.

Errors of Omission

Errors of omission occur when a standard test is not performed when it should have been—for example, admitting a patient with acute appendicitis diagnosed on CT with mild upper back pain. He underwent an appendectomy and complained of worsening upper back pain a few days later, suddenly becoming severe. He died 6 hours later and was diagnosed with an aortic dissection.

Medication Errors

Medication errors occur when the patients receive the wrong drug dose, the wrong drug, or did not receive the drug that should have been administered. For example, a patient diagnosed with a deep vein thrombosis in the postoperative setting who is not started on anticoagulation therapy.

Systems Errors

Systems errors occur when there is a failure in the processes within the healthcare system, including a communication failure or equipment failure with hardware or software. Other system errors include a failure of healthcare providers to use the established protocols. In addition, this includes ineffective protocols. An example of a systems error is a healthcare worker failing to activate the sepsis protocol in a postoperative patient who develops signs and symptoms of sepsis.

Adverse Events and Errors in Clinical Practice

Laparoscopic procedures may have led to increased recognition and quantification of technical errors. The identification of errors is just the first initial step in the improvement of patient care. However, healthcare systems need to establish an environment that fosters the discussion of errors while focusing on systemic changes to prevent future occurrences without assigning blame to the providers involved. Implementing systemic changes within a healthcare system is a complex process. One easy way to ensure compliance nationwide is by managing adverse events and errors in the hospital setting. Healthcare systems need to commit time, infrastructure, and other resources to effectively make viable changes over time to address the issue of surgical errors and adverse events in a sustainable manner.

Over the past few decades, patient safety has become more critical for providers and healthcare institutions. It is now a ubiquitous marker for quality patient care. The increased focus on medical safety is due to our patients' rapidly increasing medical complexity. Medically complex cases have an increased risk for adverse events and increased potential for patient safety incidents. Note that patient safety incidents can lead to a chiasm between patient expectations and the perception of the quality of patient care—for example, a patient who presents with a large middle cerebral artery territory infarct with multiple comorbidities. The patient receives a tissue plasminogen activator (tPA) to treat the recent stroke. A few days later, the patient developed hemorrhagic conversion of the previously noted large ischemic infarct. The patient may perceive this as an iatrogenic effect rather than a complication sometimes seen in patients with foci of the ischemic infarct. The wider the chasm between the patient's expectations and the perceived quality of care, the more dissatisfaction the patient may experience. Dissatisfaction may eventually lead to increased insurance claims filed for medical negligence. Medical negligence claims are more common in surgery cases, specifically in orthopedic surgery, trauma surgery, and obstetrics and gynecology (Vicente-Guijarro et al., 2021).

Adverse events or medical errors cause negative consequences for multiple parties—specifically, the patients directly affected as the primary victims. The healthcare providers who suffer the shame, guilt, and mental anguish of being involved in surgical errors or surgical cases with adverse events can be considered second victims. The third victims are the healthcare institutions that must address potential damages to their reputations and/or face the financial ramifications of the surgical error or adverse events (Vicente-Guijarro et al., 2021).

The compensation claims filed with the insurance agencies can indirectly quantify financial ramifications. Adverse events can increase the cost of surgical care in several ways. First, the adverse event may require additional procedures or medications to treat the complications associated with the adverse event. In addition, the clinicians involved in the surgical error or adverse event may start practicing defensive medicine, which could lead to the performance of unnecessary clinical or surgical tests as an attempt to prevent medical litigation. Thirdly, the cost of paid malpractice claims usually borne by the healthcare institution could lead to increased insurance rates over time (Vicente-Guijarro et al., 2021).

Over the past few years, patient safety research has demonstrated that mortality is not the most accurate measure of documenting preventable patient harm. Other measures of preventable harm should include diagnostic errors, decreased quality of life, patient morbidity, and loss of dignity. As such, the focus on patient safety is no longer only centered on hospitals. Instead, it has been adjusted to include all healthcare settings, including inpatient, outpatient, and home health settings.

A common problem encountered when addressing medical or surgical errors in healthcare systems is the problem of many hands, which makes it difficult to hold one person or department responsible for all errors or adverse events. Causes for errors are multifaceted and need to be thoroughly investigated to identify the actual problem and, subsequently, the solution.

Defensive medicine is all medical care provided by physicians and other clinical providers with the primary goal of preventing the risk of litigation. These redundant defensive medicine practices may increase healthcare expenditure (Garattini and Padula, 2020). Defensive medicine practices can be divided into two types: positive and negative. Positive defensive medicine practices are characterized by the provider ordering repetitive or unnecessary tests, procedures, interventions, and referrals. Negative defensive medicine practices are characterized by the provider refusing to take high-risk patients or avoiding high-risk procedures. Defensive medicine practices can also include providers feeling like lower–tiered clinicians amongst other providers because of medical or surgical errors.

Case Study

You are a preoperative nurse assigned to the OB/GYN service and are caring for a 63-year-old female, Mrs. Atem, scheduled for a hysterectomy. Before transporting the patient into the operating room. You notice that the surgical site has not been marked on the patient. Although, the surgeon's note says the site has been marked. In addition, you notice that the patient has worsening asymmetric right lower extremity pain and swelling, which was noted on the anesthesiologists' note as "mild discomfort" in the right lower extremity with a reported pain level of 2 out of 10. What is your next step?

Discussion for Case Study

Given that the surgical site is not marked, the operating surgeon should be notified so that the surgical site can be marked before transporting Mrs. Atem into the operating room. In addition, you inform both the surgeon and the anesthesiologists about the worsening asymmetric leg pain and swelling. The patient is reassessed by you, the nurse, and the anesthesiologist. The patient now reports a pain level of 7/10, with the right lower extremity appearing cool to the touch, which is new since the prior assessment. Of note, the anesthesiologist reports that the swelling was much worse at this time compared to her assessment 45 minutes prior. Therefore, it is essential to clarify findings even when you think the providers may be aware. Do not make assumptions about interval changes in patient symptoms or condition. It is always safer to err on the side of caution. While waiting for the surgical team to mark the site, a bilateral lower extremity venous ultrasound study was obtained, demonstrating extensive right lower extremity thrombus. Ultimately, the patient was started on anticoagulation, and the procedure was rescheduled.


Surgical team members must communicate effectively to provide the best patient care. It is important to raise questions or concerns upon your individual assessment without making assumptions about concurrent assessments from other multidisciplinary team members. In the perioperative setting, patients can rapidly become unstable, and it is important to voice concerns when appropriate to ensure the best patient outcomes. All team members must actively participate in the perioperative universal protocol process for improved patient outcomes.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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  • Holstine, J. B., & Samora, J. B. (2021). Reducing Surgical Specimen Errors Through Multidisciplinary Quality Improvement. The Joint Commission Journal on Quality and Patient Safety, 47(9), 563–571. Visit Source.
  • Marsh, K. M., Fleming, M. A., Turrentine, F. E., Levin, D. E., Gander, J. W., Keim-Malpass, J., & Jones, R. S. (2022). Pediatric surgical errors: A systematic scoping review. Journal of Pediatric Surgery, 57(4), 616–621. Visit Source
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  • Vicente-Guijarro, J., Valencia-Martín, J. L., Fernández-Herreruela, C., Sousa, P., Mira Solves, J. J., & Aranaz-Andrés, J. M. (2021). Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018. Journal of Patient Safety, 18(4), 276–286. Visit Source.