Evidence map›Paper›PMID 38320779›Full record

ArticleCanadian journal of surgery. Journal canadien de chirurgie

Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada.

Janice L Kwan, Lisa A Calder, Cara L Bowman, Anna MacIntyre, Richard Mimeault, Liisa Honey, Cynthia Dunn, Gary Garber, Hardeep Singh

Abstract read
PubMed Full text at PMC Publisher
In one paragraph

Article in Canadian journal of surgery. Journal canadien de chirurgie. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers.

0numbers the graph read from it
0cells of the map it votes in
3citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

3 citing papers in PubMed.

  1. Bile Duct Injury and Litigation in Laparoscopic Cholecystectomy: A Global Review of Current and Future Preventative Initiatives.Annals of surgery open : perspectives of surgical history, education, and clinical approaches · 2025
    Review
  2. Review
  3. Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

9 authors.

Janice L KwanFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh). janice.kwan@utoronto.ca.
Lisa A CalderFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
Cara L BowmanFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
Anna MacIntyreFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
Richard MimeaultFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
Liisa HoneyFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
Cynthia DunnFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
Gary GarberFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
Hardeep SinghFrom the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).

Funding

CIHR
6 · The paper itself

Abstract

backgroundDiagnostic errors lead to patient harm; however, most research has been conducted in nonsurgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm.

methodsWe performed a retrospective analysis of closed medico-legal cases and complaints using a database representing more than 95% of all Canadian physicians. We included cases if they involved a legal action or complaint that closed between 2014 and 2018 and involved a diagnostic error assigned by peer expert review to a surgeon.

resultsWe identified 387 surgical cases that involved a diagnostic error. The surgical specialties most often associated with diagnostic error were general surgery (

conclusionIn our cohort, diagnostic errors occurred in most surgical disciplines and across all surgical phases of care; contributing factors were commonly attributed to provider clinical decision-making and communication breakdown. Surgical patient safety efforts should include diagnostic errors with a focus on understanding and reducing errors in surgical clinical decision-making and improving communication.

Indexed as

MalpracticeSurgeonsCanadaDiagnostic ErrorsHumansRetrospective Studies

Identifiers

PMID38320779
PMCPMC10852193

What OpenQuestion holds

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LicenceCC BY-NC-ND
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Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.