PA PSRS Patient Saf Advis 2007 Sep;4(3):82.
Three "Never Complications of Surgery" Are Hardly That
Anesthesiology; Surgery
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​Three "Never Complications of Surgery" are Hardly That

PA-PSRS has previously reported on three complications of surgery that should never be considered risks that the patient must accept when undergoing an operation: unintentionally leaving something behind (retained foreign body;  see “Tips from PA Facilities: Enforcing the Time Out and Preventing Retained Foreign Bodies” in the June 2005 PA-PSRS Patient Safety Advisory), operating on the wrong site (wrong-site surgery; see “Doing the ‘Right’ Things to Correct Wrong-Site Surgery” in the June 2007 Advisory), and setting the patient on fire (surgical fire; see articles in the March 2007, December 2006, and September 2007 issues of the Advisory). During separate analyses of these three complications, PA-PSRS has determined the number of reports of each during the time periods of analysis for each project.  Based on reports from the Pennsylvania  Department of Health of 2,424,879 total operations in 2005 in Pennsylvania hospitals and ambulatory surgery centers,1, 2 PA-PSRS analysts calculated the chances of a patient experiencing a complication that should never be a risk that the patient must accept (see Table).

​​Table. Risk of Three "Never Complications of Surgery" ​ ​ ​ ​
ComplicationNumber of Reports during Time Period ​Time Period ​Number per Year Operations per Event (assumes 2,424,878 operations/year)​
​Retained foreign bodies (within incision)​60​12 months​60​1 per 40,415 operations
​Wrong-site surgery (partial and complete)*​116​30 months​46​1 per 52,260 operations
​Surgical Fires​83​36 months​28​1 per 87,646 operations
​Any of the three​134​1 per 18,807 operations
​* Wrong-site surgery information is derived from the following detailed, scientific study, which was authored by PA-PSRS staff: Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg 2007 Sep;246(3):395-405. ​ ​ ​ ​

 Although these “never complications of surgery” should never occur, more than 100 patients are currently anticipated to experience them every year. A reasonable goal is zero. 


  1. Pennsylvania Department of Health Bureau of Health Statistics and Research. Selected data from the annual hospital questionnaire reporting period July 1, 2004 through June 30, 2005 (Report 11-A): utilization of operating rooms in general acute care hospitals [online]. [cited 2007 Aug 6]. Available from Internet:
  2. Pennsylvania Department of Health Bureau of Health Statistics and Research. Data from the annual ambulatory surgery center questionnaire reporting period July 1, 2004 through June 30, 2005 (report 1): utilization and services by facility and county [online]. [cited 2006 Aug 7]. Available from Internet:

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