Judgment Errors in Surgical Care

J Am Coll Surg. 2024 May 1;238(5):874-879. doi: 10.1097/XCS.0000000000001011. Epub 2024 Apr 17.


Background: Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear.

Study design: The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression.

Results: Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors.

Conclusions: Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.

MeSH terms

  • Hospitalization*
  • Humans
  • Judgment*
  • Morbidity
  • Postoperative Complications / epidemiology
  • Postoperative Complications / prevention & control
  • Risk Factors