Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review

  • James J. JungEmail author
  • Jonah Elfassy
  • Peter Jüni
  • Teodor Grantcharov
Scientific Review



Adverse events occur commonly in the operating room (OR) and often contribute to morbidity, mortality, and increased healthcare spending. Validated frameworks to measure and report postoperative outcomes have long existed to facilitate exchanges of structured information pertaining to postoperative complication rates in order to improve patient safety. However, systematic evidence regarding measurement and reporting of intraoperative adverse events (iAE) is still lacking.


We searched Ovid Medline, Embase, and Cochrane databases for articles published up to June 2016 that measured and reported iAE. We presented the terms and definitions used to describe iAE. We identified the types of reported iAE and summarized them into discrete categories. We reported frequencies of iAE by detection methods.


Of the 47 included studies, 30 were cross-sectional, 14 were case-series, and 3 were cohort studies. The studies used 16 different terms and 22 unique definitions to describe 74 types of iAE. Frequencies of iAE appeared to vary depending on the detection methods, with higher numbers reported when direct observation in the OR was used to detect iAE. Twenty studies assessed severity of iAE, which were mostly based on whether they resulted in postoperative outcomes.


This study systematically reviewed the current evidence on prevalence and characteristics of iAE that were detected by direct observation, reviews of patient charts, administrative data and incident reports, and surveys and interviews of healthcare providers. Our findings suggest that direct observation method has the most potential to identify and characterize iAE in detail.


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

268_2019_5048_MOESM1_ESM.docx (2.3 mb)
Supplementary material 1 (DOCX 2349 kb)


  1. 1.
    Baker GR, Norton PG, Flintoft V et al (2004) The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ Can Med Assoc J 170:1678–1686CrossRefGoogle Scholar
  2. 2.
    Brennan TA, Leape LL, Laird NM et al (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N E J Med 324:370–376CrossRefGoogle Scholar
  3. 3.
    Zegers M, de Bruijne MC, Wagner C et al (2009) Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 18:297–302CrossRefGoogle Scholar
  4. 4.
    Zegers M, de Bruijne MC, de Keizer B et al (2011) The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies. Patient Saf Surg 5:13CrossRefGoogle Scholar
  5. 5.
    Thomas EJ, Studdert DM, Burstin HR et al (2000) Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 38:261–271CrossRefGoogle Scholar
  6. 6.
    Gawande AA, Thomas EJ, Zinner MJ et al (1999) The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 126:66–75CrossRefGoogle Scholar
  7. 7.
    Bates DW, Spell N, Cullen DJ et al (1997) The costs of adverse drug events in hospitalized patients. Adverse drug events prevention study group. JAMA 277:307–311CrossRefGoogle Scholar
  8. 8.
    Classen DC, Pestotnik SL, Evans RS et al (1997) Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 277:301–306CrossRefGoogle Scholar
  9. 9.
    Leape LL, Brennan TA, Laird N et al (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N E J Med 324:377–384CrossRefGoogle Scholar
  10. 10.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefGoogle Scholar
  11. 11.
    Greenberg CC (2009) Learning from adverse events and near misses. J Gastrointest Surg Off J Soc Surg Aliment Tract 13:3–5CrossRefGoogle Scholar
  12. 12.
    Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions. Cochrane Collaboration, OxfordGoogle Scholar
  13. 13.
    Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012CrossRefGoogle Scholar
  14. 14.
    National Institute of Health (2017) National institute of health quality assessment tool for observational cohort and cross-sectional studies. Retrieved from
  15. 15.
    Kantelhardt P, Muller M, Giese A et al (2011) Implementation of a critical incident reporting system in a neurosurgical department. Cent Eur Neurosurg 72:15–21CrossRefGoogle Scholar
  16. 16.
    Mandal K, Adams W, Fraser S (2005) “Near misses” in a cataract theatre: how do we improve understanding and documentation? Br J Ophthalmol 89:1565–1568CrossRefGoogle Scholar
  17. 17.
    Papaspyros SC, Javangula KC, Adluri RK et al (2010) Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact CardioVasc Thorac Surg 10:43–47CrossRefGoogle Scholar
  18. 18.
    Pollock JR, Hayward RD (2001) Adverse operative events in neurosurgical training: incidence, trends and proposals for prevention. Br J Neurosurg 15:312–318CrossRefGoogle Scholar
  19. 19.
    Simon JW, Ngo Y, Khan S et al (2007) Surgical confusions in ophthalmology. Arch Ophthalmol 125:1515–1522CrossRefGoogle Scholar
  20. 20.
    Singh R, Saleemi A, Walsh K et al (2003) Near misses in bladder cancer—an airline safety approach to urology. Ann R Coll Surg Engl 85:378–381CrossRefGoogle Scholar
  21. 21.
    Steeples LR, Hingorani M, Flanagan D et al (2016) Wrong intraocular lens events-what lessons have we learned? A review of incidents reported to the national reporting and learning system: 2010–2014 versus 2003–2010. Eye (Lond) 30:1049–1055CrossRefGoogle Scholar
  22. 22.
    Ugur E, Kara S, Yildirim S et al (2016) Medical errors and patient safety in the operating room. J Pak Med Assoc 66:593–597Google Scholar
  23. 23.
    Albayati MA, Gohel MS, Patel SR et al (2011) Identification of patient safety improvement targets in successful vascular and endovascular procedures: analysis of 251 hours of complex arterial surgery. Eur J Vasc Endovasc Surg 41:795–802CrossRefGoogle Scholar
  24. 24.
    Bilimoria KY, Kmiecik TE, DaRosa DA et al (2009) Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. Arch Surg 144:305–311 (discussion 311) CrossRefGoogle Scholar
  25. 25.
    de Vries EN, Eikens-Jansen MP, Hamersma AM et al (2011) Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg 253:624–628CrossRefGoogle Scholar
  26. 26.
    Dea N, Versteeg A, Fisher C et al (2014) Adverse events in emergency oncological spine surgery: a prospective analysis. J Neurosurg Spine 21:698–703CrossRefGoogle Scholar
  27. 27.
    Gawande AA, Zinner MJ, Studdert DM et al (2003) Analysis of errors reported by surgeons at three teaching hospitals. Surgery 133:614–621CrossRefGoogle Scholar
  28. 28.
    Kaafarani HM, Mavros MN, Hwabejire J et al (2014) Derivation and validation of a novel severity classification for intraoperative adverse events. J Am Coll Surg 218:1120–1128CrossRefGoogle Scholar
  29. 29.
    Mason SL, Kuruvilla S, Riga CV et al (2013) Design and validation of an error capture tool for quality evaluation in the vascular and endovascular surgical theatre. Eur J Vasc Endovasc Surg 45:248–254CrossRefGoogle Scholar
  30. 30.
    Street JT, Lenehan BJ, DiPaola CP et al (2012) Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients. Spine J 12:22–34CrossRefGoogle Scholar
  31. 31.
    Unbeck M, Muren O, Lillkrona U (2008) Identification of adverse events at an orthopedics department in Sweden. Acta Orthop 79:396–403CrossRefGoogle Scholar
  32. 32.
    James MA, Seiler JG III, Harrast JJ et al (2012) The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am 94:e2(1–12)CrossRefGoogle Scholar
  33. 33.
    Jhawar BS, Mitsis D, Duggal N (2007) Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine 7:467–472CrossRefGoogle Scholar
  34. 34.
    Meinberg EG, Stern PJ (2003) Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am 85-A:193–197CrossRefGoogle Scholar
  35. 35.
    Mody MG, Nourbakhsh A, Stahl DL et al (2008) The prevalence of wrong level surgery among spine surgeons. Spine (Phila Pa 1976) 33:194–198CrossRefGoogle Scholar
  36. 36.
    Neily J, Mills PD, Eldridge N et al (2009) Incorrect surgical procedures within and outside of the operating room. Arch Surg 144:1028–1034CrossRefGoogle Scholar
  37. 37.
    Shah RK, Nussenbaum B, Kienstra M et al (2010) Wrong-site sinus surgery in otolaryngology. Otolaryngol Head Neck Surg Off J Am Acad Otolaryngol Head Neck Surg 143:37–41CrossRefGoogle Scholar
  38. 38.
    Shen E, Porco T, Rutar T (2013) Errors in strabismus surgery. JAMA Ophthalmol 131:75–79CrossRefGoogle Scholar
  39. 39.
    Stahel PF, Sabel AL, Victoroff MS et al (2010) Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg 145:978–984CrossRefGoogle Scholar
  40. 40.
    Fabri PJ, Zayas-Castro JL (2008) Human error, not communication and systems, underlies surgical complications. Surgery 144:557–563 (discussion 563–555) CrossRefGoogle Scholar
  41. 41.
    Michalak SM, Rolston JD, Lawton MT (2016) Prospective, multidisciplinary recording of perioperative errors in cerebrovascular surgery: is error in the eye of the beholder? J Neurosurg 124:1794–1804CrossRefGoogle Scholar
  42. 42.
    Shah RK, Boss EF, Brereton J et al (2014) Errors in otolaryngology revisited. Otolaryngol Head Neck Surg Off J Am Acad Otolaryngol Head Neck Surg 150:779–784CrossRefGoogle Scholar
  43. 43.
    Shah RK, Kentala E, Healy GB et al (2004) Classification and consequences of errors in otolaryngology. Laryngoscope 114:1322–1335CrossRefGoogle Scholar
  44. 44.
    Ferroli P, Caldiroli D, Acerbi F et al (2012) Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data. Neurosurg Focus 33:E7CrossRefGoogle Scholar
  45. 45.
    Panesar SS, Carson-Stevens A, Mann BS et al (2012) Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors. BMC Musculoskelet Disord 13:93CrossRefGoogle Scholar
  46. 46.
    McElroy LM, Woods DM, Yanes AF et al (2016) Applying the WHO conceptual framework for the international classification for patient safety to a surgical population. Int J Qual Health Care J Int Soc Qual Health Care ISQua 28:166–174CrossRefGoogle Scholar
  47. 47.
    Barach P, Johnson JK, Ahmad A et al (2008) A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease. J Thorac Cardiovasc Surg 136:1422–1428CrossRefGoogle Scholar
  48. 48.
    Griffin FA, Classen DC (2008) Detection of adverse events in surgical patients using the Trigger Tool approach. Qual Saf Health Care 17:253–258CrossRefGoogle Scholar
  49. 49.
    Heideveld-Chevalking AJ, Calsbeek H, Damen J et al (2014) The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 ‘near-misses’ and adverse events. Patient Saf Surg 8:46Google Scholar
  50. 50.
    Proctor ML, Pastore J, Gerstle JT et al (2003) Incidence of medical error and adverse outcomes on a pediatric general surgery service. J Pediatr Surg 38:1361–1365CrossRefGoogle Scholar
  51. 51.
    Thiels CA, Lal TM, Nienow JM et al (2015) Surgical never events and contributing human factors. Surgery 158:515–521CrossRefGoogle Scholar
  52. 52.
    Wanzel KR, Jamieson CG, Bohnen JM (2000) Complications on a general surgery service: incidence and reporting. Can J Surg 43:113–117Google Scholar
  53. 53.
    McElroy LM, Daud A, Lapin B et al (2014) Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system. Surgery 156:1106–1115CrossRefGoogle Scholar
  54. 54.
    Christian CK, Gustafson ML, Roth EM et al (2006) A prospective study of patient safety in the operating room. Surgery 139:159–173CrossRefGoogle Scholar
  55. 55.
    Mattioli G, Guida E, Montobbio G et al (2012) Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery. Pediatr Surg Int 28:405–410CrossRefGoogle Scholar
  56. 56.
    Zingg U, Zala-Mezoe E, Kuenzle B et al (2008) Evaluation of critical incidents in general surgery. Br J Surg 95:1420–1425CrossRefGoogle Scholar
  57. 57.
    Houkin K, Baba T, Minamida Y et al (2009) Quantitative analysis of adverse events in neurosurgery. Neurosurgery 65:587–594 (discussion 594) CrossRefGoogle Scholar
  58. 58.
    Catchpole KR, Giddings AE, de Leval MR et al (2006) Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49:567–588CrossRefGoogle Scholar
  59. 59.
    Catchpole KR, Giddings AE, Wilkinson M et al (2007) Improving patient safety by identifying latent failures in successful operations. Surgery 142:102–110CrossRefGoogle Scholar
  60. 60.
    World Health Organization (2005) WHO draft guidelines for adverse event reporting and learning systems. WHO Press, Geneva, SwitzelandGoogle Scholar
  61. 61.
    Kohn L, Corrigan J, Donaldson M (2000) To err is human: building a safer health system. National Academies Press, Washington (DC)Google Scholar
  62. 62.
    Perez B, Knych SA, Weaver SJ et al (2014) Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. J Patient Saf 10:45–51CrossRefGoogle Scholar
  63. 63.
    Jung J, Jüni P, Lebovic G, et al. (2018) First year analysis of the operating room black box study, Unpublished workGoogle Scholar
  64. 64.
    Rosenthal R, Hoffmann H, Clavien PA et al (2015) Definition and classification of intraoperative complications (CLASSIC): Delphi study and pilot evaluation. World J Surg 39:1663–1671CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  1. 1.International Centre for Surgical Safety, Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  2. 2.Department of SurgeryUniversity of TorontoTorontoCanada
  3. 3.Institute of Health Policy, Management, and EvaluationUniversity of TorontoTorontoCanada
  4. 4.Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada

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