Surgical checklist protecting a patient from errors.

Is Your Surgery Safe? Unveiling the Hidden Errors in the Operating Room

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Lena Kashyap in Health & Wellness December 2025 • 4 min read.

"A deep dive into surgical case listing accuracy and how a proactive approach can minimize risks in the operating room."


In the high-stakes world of surgery, precision and accuracy are paramount. While much attention is given to the skills of the surgeons and the sophistication of medical technology, a seemingly mundane aspect – the surgical case listing – can harbor hidden risks. A surgical case listing is more than just a schedule; it's a critical communication tool that ensures everyone in the operating room is on the same page. Errors in these listings can lead to confusion, inefficiency, and, in the worst-case scenario, adverse patient events.

Imagine a scenario where the surgical listing incorrectly identifies the side of the body for a procedure. This seemingly small error could lead to a cascade of mistakes, potentially jeopardizing the patient's health. Recognizing the significance of this often-overlooked area, a team of researchers at a high-volume academic medical center embarked on a study to analyze the incidence, types, and detection methods of surgical listing errors. Their goal was to implement a system to reduce these errors and enhance patient safety.

This study, published in the Archives of Surgery, sheds light on the prevalence and nature of surgical listing errors. It offers valuable insights for healthcare professionals and anyone interested in understanding the complexities of patient safety in the operating room. By examining the root causes of these errors and implementing targeted solutions, the researchers demonstrated how a proactive approach can significantly improve surgical accuracy.

The Scope of the Problem: Understanding Surgical Listing Errors

Surgical checklist protecting a patient from errors.

The study, conducted at a tertiary care academic hospital, analyzed all reported errors and discrepancies between the surgical listing and the actual procedure performed during 2008. With a staggering 55,197 surgical procedures performed that year, the researchers identified 759 listing errors, translating to an error rate of 1.38%. While no wrong-site surgeries occurred, the types of errors uncovered were revealing:

The data paints a clear picture of where the system was falling short. But the study didn't stop at simply identifying the errors. The researchers were determined to understand why these errors were occurring in the first place.

  • Missing Laterality: A significant 66% of the errors involved missing information about whether the procedure was to be performed on the right or left side of the body.
  • Incorrect Side: 14% of errors listed the wrong side of the body for the procedure.
  • Incorrect Listing: 11% of errors involved incorrect procedure listings unrelated to laterality.
  • Other Errors: The remaining 9% encompassed a variety of miscellaneous errors.
To get to the bottom of these issues, the team used a causal tree analysis. This is a method where they visually mapped out the possible causes, looking at all the factors that might have influenced the outcomes and error in data.. By mapping the root causes that lead to surgical listing inaccuracies, they were able to pinpoint areas ripe for improvement.

The Future of Surgical Safety: A Call for Standardized Systems

The study's findings underscore the critical need for standardized, electronic surgical listing systems with built-in error-proofing mechanisms. By minimizing variability and requiring laterality information, these systems can significantly reduce the incidence of surgical listing errors and improve patient safety. The team's success in reducing error rates in gynecologic and colorectal surgery serves as a compelling example of the power of technology and process improvement. As healthcare systems continue to embrace digital solutions, the lessons learned from this study can pave the way for safer and more accurate surgical practices nationwide.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

Everything You Need To Know

1

What is a surgical case listing and why is it important?

A surgical case listing is a schedule that provides crucial information, acting as a critical communication tool within the operating room. It's vital for ensuring everyone involved in the procedure, including surgeons, nurses, and anesthesiologists, is on the same page regarding the planned operation. Errors in the surgical case listing can lead to confusion, inefficiencies, and potentially, adverse patient events, emphasizing its importance in patient safety.

2

What types of errors were most common in the surgical case listings?

The study identified several types of errors. The most prevalent was Missing Laterality, accounting for 66% of the errors. These errors involved a lack of information about whether the procedure was to be performed on the right or left side of the body. Incorrect Side errors represented 14%, while Incorrect Listing errors made up 11% of the total, and the remaining 9% encompassed other miscellaneous errors.

3

How did the study analyze the causes of surgical listing errors?

The researchers utilized a causal tree analysis. This method helped them map out possible causes, considering various factors that might have influenced the outcomes and errors in the data. By visually representing these causes, they pinpointed areas ripe for improvement within the surgical processes.

4

What impact can errors in surgical case listings have on patient safety?

Errors in surgical case listings can directly jeopardize patient safety. For example, an incorrect specification of the surgical site (e.g., wrong side of the body) can lead to serious medical errors. Incorrect listings can lead to delays, confusion, and inefficiencies during the procedure, increasing the risk of complications and negatively impacting patient outcomes. The study emphasizes that seemingly minor errors in these listings can trigger a cascade of events that threaten patient well-being.

5

What solutions were recommended to prevent surgical listing errors, and what role does technology play?

The study advocates for the implementation of standardized, electronic surgical listing systems with built-in error-proofing mechanisms. The use of digital systems with features that require laterality information and minimize variability can significantly reduce the incidence of surgical listing errors. The research highlights the success achieved by the team in reducing error rates in gynecologic and colorectal surgery, demonstrating the power of technology and process improvement in enhancing surgical accuracy and patient safety.

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