The inclusion criteria for this study are 127 medical errors lawsuits against general surgeons that have been closed between January 2018 and January 2021, and the data were provided by four professional appraisal institutions located in Nanjing, when one of the last two authors (Shi X and Tang WH) was randomly selected participating in medical damage identification hearing as a member of expert group. Exclusion criteria are the main targets of litigation against other clinical specialists, such as gastroenterology or gynecology. The four appraisal institutions are Medical Damage Identification Office of Jiangsu Medical Association, Medical Damage Identification Office of Nanjing Medical Association, Forensic Expertise Institute of Nanjing Medical University and Nanjing Southeast Forensic Science Service, all of which were located in Nanjing and mainly provided regional coverage such as Jiangsu, Anhui and Henan, although these institutions were nation-wide coverage. Reviewed data typically included both of plaintiff’s and defendant's statement of views, the relevant medical and legal documents, the expert on-site hearing records, expert analysis opinions and appraisal conclusions.
Based on Griffin's work and the data characteristics of 127 medical error lawsuits collected in this study, flawed behavioral practice patterns in this study were slightly modified as following:
1. Failed sufficiently to communicate with the patient and/or family in operative surgical informed consent, e.g. lack to provide alternatives of “evidence-based” management and their pros and cons before surgery, or lack to re-communicate with the family when an unexpected event emerges and an alternative procedure needed to take during surgery.
2. Failed to adequately make an preoperative or intraoperative assessment of the primary surgical conditions resulting in an unneeded surgery or an inadequate procedure resulting to severe postoperative complications, for example, having a wrong segmental mastectomy for a patient with an nonpalpable breast lump, or taking a total thyroidectomy for a patient with bilateral thyroid nodules without preoperative needle aspiration cytology or intraoperative frozen pathology, and causing a complication of permanent hyperparathyroidism or bilateral recurrent nerve palsy.
3. Failed to adequately assess and control comorbidities before surgery, e.g., malnutrition, diabetes, coronary artery disease or chronic obstructive pulmonary diseases.
4. Failed to meet prevention obligations, e.g. operative report or on-site hearing could not produce evidence to reflect that the protective measures were taken by the surgeon in question during surgery against organ structure injuries such as the recurrent laryngeal nerves or parathyroids.
5. Failed in time to check and analyze carefully investigative report, such as hypokalemia, metastatic signs showed in preoperative imaging, and so forth.
6. Failed to visit a patient as required, e.g. series of closely monitoring of abdomen pain or hypovolemic status.
7. Failed to pursue or have some inside into an abnormal symptom, sign, or investigation report findings during postoperative care, e.g. mistaking the high fever in a patient following gastrectomy as pneumonia without suspecting a duodenal leakage.
8. Failed to consult a relevant specialist and have a support.
9. Failed to adhere to the suitable scope of practice, e.g. implementation of a surgery which the surgeon was not capable of accomplishing, such as bile duct injury repair or complex intestinal fistula repair.
10. Failed to truthfully inform intraoperative complications (hiding the truth), such as accidental rupture of spleen leading to removal of the spleen during gastrectomy surgery, or injury to bile duct, even combined with hepatic artery and portal vein injuries, during cholecystectomy surgery.
11. Failed to adhere to other work routines (except the above-mentioned patterns), including: insufficient handover of discharge note, e.g. lack to inform the patient of a needed radiotherapy following breast conservative surgery plus chemotherapy resulting in local skin cancer recurrence; lack in sharing-decision-making for surgical thyroidectomy causing an injury to recurrent laryngeal nerve in a patient with bilateral thyroid nodules with needle cytology diagnosed of follicle-filled tumors; and performing a gas laparoscopic surgery on patient with diffuse peritonitis and septic shock.
The data for this study are all nominal and ordinal level. Statistical analysis is tested using Fisher's exact probability tests. Any result that did not meet the P < 0.05 was not considered as meeting the level of statistical significance.