Medical Errors in Orthopaedics. Results of AAOS Member Survey

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Medical Errors in Orthopaedics. Results of an AAOS Member Survey

David A. Wong, James H. Herndon, S. Terry Canale, Robert L. Brooks, Thomas R. Hunt, Howard R. Epps,
Steven S. Fountain, Stephen A. Albanese and Norman A. Johanson
J Bone Joint Surg Am. 2009;91:547-557. doi:10.2106/JBJS.G.01439
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547
COPYRIGHT(cid:2)2009BYTHEJOURNALOFBONEANDJOINTSURGERY,INCORPORATED
Medical Errors in Orthopaedics
Results of an AAOS Member Survey
ByDavidA.Wong,MD,MSc,FRCS(C),JamesH.Herndon,MD,S.TerryCanale,MD,RobertL.Brooks,MD,PhD,MBA,
ThomasR.Hunt,MD,HowardR.Epps,MD,StevenS.Fountain,MD,StephenA.Albanese,MD,andNormanA.Johanson,MD
Background: TherehasbeenwidespreadinterestinmedicalerrorssincethepublicationofToErrIsHuman:Buildinga
Safer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy of
OrthopaedicSurgeonshascompiledtheresultsofamembersurveytoidentifytrendsinorthopaedicerrorsthatwould
helptodirectqualityassuranceefforts.
Methods: Surveysweresentto5540Academyfellows,and917werereturned(aresponserateof16.6%),with53%
(483) reporting an observed medical error in the previous six months.
Results: Ageneralclassificationoferrorsshowedequipment(29%)andcommunication(24.7%)errorswiththe
highestfrequency.Medicationerrors(9.7%)andwrong-sitesurgery(5.6%)representedseriouspotentialpatientharm.
Twodeathswerereported,andbothinvolvednarcoticadministrationerrors.Bylocation,78%oferrorsoccurredinthe
hospital(54%inthesurgerysuiteand10%inthepatientroomorfloor).Thereportingorthopaedicsurgeonwasinvolved
in60%oftheerrors;anurse,in37%;anotherorthopaedicsurgeon,in19%;otherphysicians,in16%;andhousestaff,
in13%.Wrong-sitesurgeriesinvolvedthewrongside(59%);anotherwrongsite,e.g.,thewrongdigitonthecorrectside
(23%);thewrongprocedure(14%);orthewrongpatient(5%ofthetime).Themostfrequentanatomiclocationswerethe
kneeandthefingersand/orhand(35%foreach),thefootand/orankle(15%),followedbythedistalendofthefemur
(10%) and the spine (5%).
Conclusions: Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance
effortsandmore refined research can be addressed toward areaswithhigher erroroccurrence(equipmentand
communication) and high risk (medication and wrong-site surgery).
ThePatientSafetyCommitteeoftheAmericanAcademyof (cid:2) Domedicalerrorsinorthopaedicsmaptorecognized
Orthopaedic Surgeons (AAOS) has recently completed errorclassification systems?
ananalysisofamembershipsurveyregardingmedicaler- (cid:2) Can trends that might assist in focusing orthopaedic
rorsinorthopaedicpractice.Theresultsweresoughtprimarily quality assurance effortsbe identified?
toassistongoing,day-to-dayeffortsoftheAAOSfellowshipto
keeppatientssafe.AnadditionalbenefitwastohelpthePatient TheAAOShasbeenarecognizedleaderamongprofessional
SafetyCommitteeandtheAcademyleadershiptoidentifyand medicalsocietiesinproactivelyconfrontingissuesofmedicaler-
prioritizepatientsafetyissues. rorsandpatientsafety1-3. The first major safety initiative under-
The researchquestions framedfor the surveywere: taken addressed wrong-site surgery. The AAOS Wrong Site
SurgeryTaskForcepublisheditsrevisedreportin19984.The
(cid:2) Will a member survey show occurrence of medical resulting voluntary program was christened the ‘‘Sign Your
errors in orthopaedicpractice? Site’’ or ‘‘SYS’’ initiative. As a voluntary program, Sign Your
(cid:2) Dowrong-sitesurgeriescontinuetooccurdespitethe Sitewas not fullyembraced bythe Academy fellowship5.
AAOS Sign Your Site program and the Joint Commission on The2000publicationoftheInstituteofMedicinereport
the Accreditation of Healthcare Organizations (JCAHO) Uni- entitledTo Err Is Human: Building a Safer Health System6 rep-
versalProtocol? resents the seminal event stimulating widespread interest in
Disclosure:Theauthorsdidnotreceiveanyoutsidefundingorgrantsinsupportoftheirresearchfororpreparationofthiswork.Neithertheynoramemberof
theirimmediatefamiliesreceivedpaymentsorotherbenefitsoracommitmentoragreementtoprovidesuchbenefitsfromacommercialentity.
Acommentaryisavailablewiththeelectronicversionsofthisarticle,onourwebsite(www.jbjs.org)andonourquarterlyCD-ROM/DVD(callour
subscriptiondepartment,at781-449-9780,toordertheCD-ROMorDVD).
JBoneJointSurgAm.2009;91:547-57 d doi:10.2106/JBJS.G.01439
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Fig.1
TheJointCommissionontheAccreditationofHealthcareOrganizations-NationalQualityForum(JCAHO-NQF)
ClassificationofMedicalErrors.Errorsareprimarilyanalyzedthrougheachoffivenodes(impact,type,domain,
cause,andpreventionormitigation).Eachprimarynodehasfurthersubclassificationoptionsondescending
levels(secondary,tertiary,andquaternary).Theexampleillustratedisthesubclassificationofanincident
thatoccursinthehospitalsetting(theprimarynodeisdomain,thesecondarynodeissetting,thetertiary
nodeishospital,andthequaternarynodeisemergencyroom,operatingroom,intensivecareunit,and
nursingunit).
medicalerrorsintheeyesofthepublic,newsmedia,politicians, porting.’’11TheJCAHO-NQFtaxonomy(Fig.1)thushaswide
and the medical profession. The Institute of Medicine’s con- acceptanceand potential application.
clusionthatbetween44,000and98,000patientdeathsperyear Theotherprofessionalmedicalsocietytopublishapatient
resulted from medical errors in hospitals in the United States safetymembershipsurveyinvolvesear,nose,andthroatsurgery12
was widely publicized. Asa result, patientsafety has become a undertheauspicesoftheAmericanAcademyofOtolaryngology-
noteworthy issueinmanyquarters. Head and Neck Surgery (AAO-HNS). A general classification
To date, meaningful data on medical errors have come system of medical errors was developed by those authors after
fromregulatoryagenciesandanothersurgicalsubspecialtyso- reviewoftheotolaryngologydata(Table I). The ear, nose, and
ciety.Theregulatoryagencywiththemostexperienceanalyzing throat surgery classification was used for broad analysis of the
medical errors is probably the Joint Commission on the Ac- orthopaedic survey. This allows some general comparisons of
creditationofHealthcareOrganizations(JCAHO).Atthetime errorsbetweenphysiciansubspecialtysurgicalgroups.
of publication of To Err Is Human, the JCAHO was already Drug-relatederrorshavebeenaparticularinterestareainthe
looking at some specific errors (i.e., medication errors and popularpress13andafocusofqualityassuranceeffortsinhospi-
wrong-sitesurgery)bymeansofitsSentinelEventsprogram7,8. tals14. The National Coordinating Council for Medication Error
Other sentinel events (e.g., patient death) may have errors Reporting and Prevention (NCC MERP) has developed a classi-
identifiedduringthe‘‘RootCauseAnalysis’’requiredforevery ficationsystemofmedicationerrorsonthebasisofthedegreeof
sentinel event. In addition to tabulating the incidence of sen- seriousnessand/orharm(thepotentialforfatalerror)15.Thereare
tinel events, the JCAHO developed a Patient Safety Event nine categories (A to I). The potential for harm ranges from A
Taxonomy for additional subanalysis of medical errors9. This (‘‘Circumstancesoreventsthathavethecapacity tocauseerror,’’
taxonomy system has been adopted by the National Quality e.g.,informationonallergiesunavailableforanunconscious
Forum (NQF)10. The NQF is a public-private partnered, not- traumavictim)toI(‘‘Anerroroccurredthatmayhavecontributed
for-profit organization ‘‘created to develop and implement a toorresultedinthepatient’sdeath’’).Bothdirectpatientdeathsin
national strategy for health care quality measurementand re- theAAOSsurveywereassociatedwithmedicationerrors.Itwas
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AAOSAnnualMeetingforaface-to-facedescriptionofcritical
TABLEITheEar,Nose,andThroatSurgeryClassification incidents and question feedback (again administered by Ax-
SystemComprisingSixteenGeneralCategoriesof
xiomstaff).
MedicalErrors
Thepilotgroupwasinitiallychosenaccordingtoageand
DistributionofErrors* practicestatus(resident,memberfromthirty-fivetoforty-nine
yearsold,memberoverfiftyyearsold,oremeritusfellow).The
Ear,Nose, Orthopaedic
group included representation from different practice settings
Ear,Nose,andThroat andThroat Surgery
SurgeryClassification12 Surgery(N=212) (N=483) (academic or private and urban or more rural), although this
criterion was not a specific factor for inclusion. Orthopaedic
Historyandphysical 1.4% 1.2% nurses were also part of the critical incident pilot, but it was
Differentialdiagnosis 1.4% 3.3% ultimatelydecidedtosurveyphysiciansonly(similartotheear,
orfinaldiagnosis nose,andthroatstudy).Thetimeframeforerrorwasmoreopen-
Testing 10.4% 1.4% endedinthepilotaswewereprimarilyinterestedintherichnessof
Surgicalplanning 9.9% 1.7% the responses and therefore the reliability of the scripted ques-
Wrong-sitesurgery 6.1% 5.6% tions,whichultimatelyhelpedtorefinethesurvey.Thefeedback
suggestedthatpatient-safetyquestionswereunderstandableand
Anesthesia-related 3.3% 0.6%
answered reliably by all segments of the membership. Axxiom
Drugonsurgicalfield 3.8% 0.0%
thoughtthatthethirty-fivetoforty-nine-yearagegroupprovided
Technical 19.3% 13.0%
moredetailedresponsesintheopen-endeddescriptionportionof
Retainforeignbody 0.9% 1.2% thequestioning.Richresponseswereobtainedfrom all groups.
Equipment-related 9.4% 29.0% No en facedifferenceswerenotedaccordingtomemberstatus,
Postoperativecare 8.5% 3.9% age,orpracticesituation.Giventhesecircumstances,thelimited
Medicationerrors 13.7% 9.7% available funding, and consideration of the fact that the survey
research questionsweredirected to the occurrenceand/orclas-
Nursingand/orancillary 0.5% 3.9%
sificationlevelratherthantotherapeuticsorclinicalintervention,
Administrative 6.6% 2.9%
itwasthoughtthatwecoulddistributethesurveyaccordingtothe
Communication 3.8% 24.7%
standardmailing protocolinplaceattheAAOSDepartmentof
Miscellaneous 0.9% 15.7%
Researchwithoutfurtherdivision,andaformalstatisticalanalysis
ofinternalconsistencywasnotperformed.
*ErrorsmaymaptomorethanonecategoryintheAAOSsurvey.
Thesurveyusedthesameoperationaldefinitionofmedical
errorasthatintheear,nose,andthroatinstrument12perDovey
thereforethoughtappropriatetobreakdowntheorthopaedic etal.16.‘‘Anythingthathashappenedanywhereinyourpractice
medicationerrorswithuseoftheNCCMERPsystem. (office, hospital, operating room, emergency room, etc.) that
wasnotanticipated,shouldnothavehappened,andmakesyou
Materials and Methods say‘Idon’twantthistohappenagain’.Itcanbesmallorlarge,
Anorthopaedicmedicalerrorssurveywasdevelopedbythe administrative or clinical—anything that you feel could be
AAOS Patient Safety Committee with the assistance of avoidedin the future.’’
theAAOSDepartmentofResearchandconsultationfromthe Thedefinitionwasprintedatthebeginningofthesurvey.
marketing research firm Axxiom Healthcare Alliance. The or- TheDovey interpretationisrecognizedasa broad,very inclu-
thopaedicsurveywasbasedontheear,nose,andthroatsurgery sionary characterization of medical error. The potential for
instrument previously reported by Shah et al.12, with minor blurringthelinebetweenacomplicationandamedicalerroris
specialty-specificmodifications.TheAAOSDepartmentofRe- recognized.However,itwasdecidedtousethesamedefinitionas
search engaged Axxiom Healthcare Alliance to assist in the theear,nose,andthroatsurgerysurveyforconsistency.Thetime
feasibilityandpilottestingfromwhichtheorthopaedicsurgery- frameforreportingofmedicalerrorswasalsochosentoreflect
adaptedversionofthesurvey wasproduced.Thisearlycritical theear,nose,andthroatsurgeryinstrument(sixmonths).
incidentresearchconfirmedthehypothesisorresearchquestion Ontheorthopaedicsurveyinstrument,theerrordefinition
that medical errors were occurring in orthopaedics, thus sug- wasfollowedbysixinquiriesifanerrorwasreported.Theseare
gestingthatawidersurveywouldbeworthwhileandapplicable specificallyoutlinedintheResultssection(questions1through
to orthopaedic clinical practice. Responses also indicated that 6).Theresponseformatforthesequestionswasmultiplechoice
established classification systems, suchas the ear, nose, and (some using ‘‘all that apply’’ so that responses could fall into
throatsurgerygeneralclassification12,theJCAHO-NQFroot multiplecategories)followedbyawrite-inspacefor‘‘other.’’The
causetaxonomy9,10, and the NCC MERP medication errorclas- multiplechoiceoptionsandtheresponsesforeachquestionare
sification15,werelikelyappropriateformappingthedata. outlinedinTablesIIthroughVII.
The first phase pilot (twenty-four subjects) was admin- The respondent was then asked to insert a narrative
isteredbyAxxiomstaff(toreducebias)bymeansofatelephone description of the event in a blank space. No patient-specific
interview.Subsequently,afocusgroupwasconvenedatthe2004 datawererequested.
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patientsafety)reviewedtherawdataand/orcategorizationand
TABLEIIAtWhatStageintheCareCycleDidThis confirmedthefinalclassification.AmodifiedDelphiconsensus
IncidentOccur?
methodologywasused.Equipmentandcommunicationstask
Diagnosis 7% forces(four-personsubcommitteesofthePatientSafetyCom-
mittee)similarlyreviewedthedataandconfirmedtheclassifi-
Preintervention 7%
cations in these subdivisions. Incidents could tally in several
Intervention(treatmentorsurgery) 61%
subcategories, resulting in variable numerators and denomi-
Postintervention(follow-upcare) 16%
nators.Reporting isthusprimarilyexpressedwithuseofper-
Fromtests 3%
centages(insimilarfashionandallowinggeneralcomparisonto
Other 3%
theear,nose,andthroatsurgerysurvey).
Unknownornoresponse 3%
Ear, Nose, and Throat Surgery General Error
Classification System
TABLEIIIWhereDidThisIncidentOccur?
AgeneralerrorclassificationsystemwasdevelopedbyShahetal.12
from the ear, nose, and throat surgery survey. Sixteen categories
Office 8%
(TableI)wereusedtosubclassifyincidents.Thesystemisgeneral
In-officesurgery 1%
Otherin-officeincident 7% inscope.Errorswerebrokenintobroadcategoriessuchaserrors
in diagnosis, medical management, equipment, and wrong-site
Hospital 78%
surgery.
Surgery 54%
Patientroomornursingunit 10%
JCAHO-NQF Error Classification System
Emergencyroom 6%
This is a more detailed system developed from experience of
Unknown 2%
Ambulatorycare 2% JCAHO9,10inevaluatingrootcauseanalysesintheSentinelEvents
Otherarea 2% program.Thesystemismultitiered(primary,secondary,tertiary,
Laboratory 1% andquaternarylevels)andappearssimilar toadecision-treeal-
Rehabilitation 1% gorithm(Fig.1).Eacherrorisinitiallymappedthroughfivepri-
mary nodes (impact, type, domain, cause, and prevention or
Ambulatorycarecenter 7%
mitigation).Ateachsubsequentlevel,assigningtheincidenttoa
Long-term-carefacility 1%
categoryleadstofurthersubclassificationonthenextleveldown.
Otherfacility 2%
Unknownornoresponse 4%
TABLEIVWhoWasInvolvedinThisIncident?*
ThesurveywassenttoacohortfromtheAAOSmailinglist
Myself 60%
(5540ofthetotalmembershipofapproximately20,000)bythe
Nursingstaff 37%
AAOS Department of Research. The members surveyed were
Anotherorthopaedicsurgeon 19%
identifiedbytheDepartmentofResearchaccordingtoprotocols
Anotherphysician(nonorthopaedic) 16%
in place to distribute surveys evenly across the AAOS mailing
Internorresident 13%
list(with aview tolimit theburden ofindividual membersto
Radiology 7%
respond to frequent requests). The survey was forwarded in
Nursepractitionerorphysicianassistant 5%
August2005.Responseswereaccepteduntiltheendoftheyear.
Laboratorytechnician 2%
Responsesincludednopatient-specificinformation. Infor-
Pharmacy 2%
mation was collated by the AAOS Department of Research.
Dataweremappedprimarilybythethreeclassificationsystems Therapist 1%
previously specified (ear, nose, and throat surgery general Othersupportpersonnel 23%
classification;JCAHO-NQFrootcausetaxonomysystem; and Surgicaloroperating-roomtechnician 4%
Manufacturer’srepresentative 3%
NCC MERP classification for drug errors). The responses
Administration 2%
generally were classified directly, but the research department
Equipmentmanagerand/ormanagement 2%
staff identified some situations for which clinical input was
Anesthesiologist 1%
requestedtoconfirmmappingtoaclassificationcategory.For
Assistants(SA,CRNA,etc.) 1%
example,in theNCCMERPanalysis of drugerrors,categori-
Patientorpatientfamily 1%
zationwasclearifadeathhadresulted,but,forsomedescrip-
Othercaregiver 1%
tions,the researchstaff wanted clinical input intowhether an
Miscellaneous 1%
errorfellintothe‘‘noharm’’or‘‘temporaryharm’’categories.A
classification task force (the Director of the Department of
*Multipleresponseswereaccepted.SA=surgicalassistant,and
Research,theChairmanofthePatientSafetyCommittee,and CRNA=certifiedregisterednurseanesthesiologist.
anAAOSpastpresidentwithspecificinterestandexpertisein
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3. Who was involved in this incident? (Select all that
TABLEVHowWouldYouClassifyThisEvent?* apply) (Table IV)
Between the reporting orthopaedic surgeon (60%) and
Communicationsfailure 24.7%
otherorthopaedicsurgeons(19%),AAOSfellowswereinvolved
Equipmentand/orinstrumentationproblemin 20.0%
inalmostallofthereportedincidents.Nursingstaff(37%)were
operatingroom
thenextmostfrequent,followedbynonorthopaedicphysicians
Impropertechniqueand/orphysicianimpairment 12.7%
(16%)andinternsandresidents(13%).
Patientinjuryevent 10.6%
4. How would you classify this event? (Select all that
Equipmentproblemwithimplants 9.0%
apply) (Table V)
Wrong-sitesurgery 8.2%
Communication failure and equipment and/or instru-
Medicationerror 8.2%
ment problemswereclearly the high-frequencycategories.
Transition-of-careproblem 6.3%
5. What wasthe outcomeof the incident?(Table VI)
Imagingstudiesproblem 6.1%
Fiftypercentoftheincidentshadnodirectpatienteffect
Bloodortissueevent 5.5%
(41% had no adverse event and 9% were a near miss). Tem-
Adversedrugreaction 5.3%
porary morbidity occurred in 29%, permanent morbidity in
Patientidentificationproblem 2.0% 14%, and death in 3% of the incidents.
Antibioticprophylaxisevent 1.6% 6. Did the incident resultin litigation?(Table VII)
Other 17.8% Respondentsnotedlitigationinonly4%oftheincidents.
Data overview suggested another category of mapping,
*Multipleresponseswereaccepted.
as incidents involving injury to health-care workers were re-
ported in the survey.
Anumberisassignedtotheoptionsineachlayerofsubclas- 7. To whom did the incident occur or who was the
sification.Frequencydatacanbeascertainedforeachcategory injuredperson? (Table VIII)
atthevariouslevelsofanalysis.Aperiodisplacedbetweenthe Patients accounted for the largest portion (65%). A con-
numbersassignedateachlevelofclassification.Awrong-site siderablesegmentofincidents(24%)weregeneralinnatureand
surgeryoccurringinthehospitaloperatingroom(classifica- didnotimpactdirectlydowntothepatientlevel.Forexample,a
tion3.01.01.05)iscategorizedthroughthetierofoptionsas prosthesisofanincorrectsizethatpassedontothefieldbutwas
follows(Fig. 1):
(cid:2) Primary node: domain (3)
TABLEVIWhatWastheOutcomeoftheIncident?
(cid:2) Secondaryoptions:setting(3.01)
(cid:2) Tertiaryoption: hospital (3.01.01) Noadverseevent 41%
(cid:2) Quaternaryoption: operating room (3.01.01.05)
Nearmiss 9%
Adverseeventwithshort-termmorbidity 29%
Suchasystemisusefulforinvestigatorsdelvingintothe
Adverseeventwithpermanentmorbidity 14%
moredetailedanalysis ofrootcauseissues.
Death 3%
Role of Funding Unknownornoresponse 4%
Therewasno external funding for this study.
Results
TABLEVIIDidtheIncidentResultinLitigation?
Of the 5540 surveys, 917 were returned (a response rate of
16.6%).Theresponserateintheear,nose,andthroatsur- Yes 4%
gerysurvey12(18.6%)wassimilar.Ofthe917orthopaedicsurgeon No 57%
respondents,483(53%)hadnotedamedicalerrorintheprevious Undeterminedorpotentially 30%
sixmonths.
Unknownornoresponse 9%
There were six primary questions in the survey instru-
ment foreach reported incident:
1. Atwhatstageinthecarecycledidthisincidentoccur?
TABLEVIIIIncidentsNotedforPersonInjuredortoWhom
(Table II)
IncidentOccurred
Treatmentor surgeryhad the highest percentage (61%)
followedby postintervention or follow-up care(16%). Incidentoccurredtopatient 65%
2. Wheredid this incident occur? (Table III) Incidentoccurredtostaff 6%
Themostfrequentlocationwasthehospital(78%).The Generalincidentwithnodirectimpact 24%
office(8%)andambulatorycarecenter(7%)werethelocation
Unknownorunabletoclassify 5%
of a smaller numberof incidents.
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discovered before implantation would be an error; however, it Subanalysis of Equipment, Communication, Medication
would be considered as general in nature and not impacting Errors, and Wrong-Site Surgery
down to the patient or person level. Incidents that directly The general classifications indicated that orthopaedic errors
involvedmedicalproviders(e.g.,needlesticks)accountedfor6%. occurred with highest frequency in the categories of equip-
ment(29%)andcommunication(24.7%).However,themost
Comparison of Ear, Nose, and Throat Surgery and
Orthopaedic Data (Table I)
Table I shows the frequency data for ear, nose, and throat TABLEIXJCAHO-NQFTaxonomy
surgery and for orthopaedics for all sixteen categories in the
PercentageofTotal
ear,nose,andthroatsurgeryclassificationsystem12.Intheear,
No.ofIncidents†
nose, and throat surgery survey12, the medical errors that oc- ImpactResultingfromIncident* (N=483)
curred with the highest frequency were technical incidents
(19.3%)followedbymedication(13.7%)andtesting(10.4%) 1.01Medical 0.2
incidents.Wrong-sitesurgeryrepresented6.1%ofthereports. 1.01.01Psychological 0.1
In orthopaedics, the top two categories (equipment at 29% 1.01.01.01Noharm 0.0
andcommunicationat24.7%)madeupmorethanhalfofthe 1.01.01.02Nodetectableharm 0.0
incidents(53.7%).Medicationerrorsaccountedfor9.7%and 1.01.01.03Mild-temporaryharm 0.0
wrong-sitesurgery for 5.6%. 1.01.01.04Mild-permanentharm 0.0
1.01.01.05Moderate-temporaryharm 0.0
1.01.01.06Moderate-permanentharm 0.0
JCAHO-NQF Taxonomy (Fig. 1, Table IX)
1.01.01.07Severe-temporaryharm 0.0
This classification works like a branching decision tree with
1.01.01.08Severe-permanentharm 0.0
eachupperlevelboxpotentiallydividingintoseveralboxeson
1.01.01.09Profoundmentalharm 0.1
thenextlowerlevel(Fig.1).Theprimarynode(anupperlevel
box)for‘‘impact’’reflectsthedegreeofharmtothepatient9,10. 1.01.02Physical 83.6
Forthenextlevelsubclassificationofimpact,orthopaedicnar- 1.01.02.01Noharm 11.4
1.01.02.02Nodetectableharm 23.8
rativesrarelymentionedpsychologicalissues(0.2%)andwere
1.01.02.03Minimal-temporaryharm 4.6
directed mostly to the physical aspects (83.6%). This area of
1.01.02.04Minimal-permanentharm 0.6
classificationhasthepotentialforunderreporting,particularly
1.01.02.05Moderate-temporaryharm 18.2
on the psychological side.
1.01.02.06Moderate-permanentharm 7.2
Further dividing the physical subcategory into nine ad-
1.01.02.07Severe-temporaryharm 11.6
ditional subcategories in the next level down shows the most
1.01.02.08Severe-permanentharm 4.1
frequent subclassification was ‘‘no detectable harm’’ (23.8%),
1.01.02.09Death 2.1
followedby‘‘moderate-temporaryharm’’(18.2%)and‘‘severe-
1.02Nonmedical
temporaryharm’’(11.6%).Theworstsubcategoryof‘‘physical’’
1.02.01Patient/familysatisfaction: NA
impactwas‘‘death’’(2.1%).
premitigationandpostmitigation
In the secondary subclassification of the primary node
1.02.01.01Extremelydissatisfied NA
(upperbox)‘‘setting,’’theoperatingroomhadtheoverallhighest
1.02.01.02Dissatisfied NA
frequencyoferror(54.2%).Subacutecaresettingswerethe
1.02.01.03Neutral NA
next most frequent location (13.5%). The emergency room
1.02.01.04Satisfied NA
had 6%of theerrors,and interventionalradiologyhad 2.5%. 1.02.01.05Extremelysatisfied NA
1.02.02Legal 2.0
NCC MERP Classification of Medication Errors (Table X)
1.02.03Social NA
Adetailedbreakdownofmedicationerrorsintonineclassesis
1.02.04Economic NA
outlined in Table X. In addition, there are four subclassifica-
Unknown 16.1
tions according to the potential or actual harm level of the
error.Theleastseriouscategory,inwhichnoerroroccurredat
*Primary node impact (1) with secondary subclassification to
thepatientlevelbuteventshadacapacityforerror,comprised
medical (1.01) and nonmedical (1.02), followed by tertiary sub-
4.3%. An example of this category would be the ordering of classification,e.g.,psychological(1.01.01),andquaternarysub-
an antibiotic to which the patient was allergic (technically, a classification into degree of harm, e.g., no harm (1.01.01.01).
medical error),but the error was caught beforethe antibiotic Orthopaedic errors appear principally to impact on the patient
was administered (no effect at the patient level, but the ca- physically (1.01.02), comprising 83.6% of errors. The most fre-
quent physical subclassification was ‘‘no detectable harm’’
pacity for harm existed). Errors at the patient level that in-
(23.8%), followed by ‘‘moderate-temporary harm’’ (18.2%) and
volvednoharmwere48.9%.Instancesthatreachedthepatient
‘‘severe-temporary harm’’ (11.6%). The two worst categories of
level and caused patient harm constituted 42.5%. The fourth
injury and their relative incidence were severe-permanent harm
andmostseriouscategoryoferrorresultinginorcontributing (4.1%)anddeath(2.1%).†NA=notapplicable.
to a patientdeathwas4.3% (twopatients).
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life-threatening errors involved drug adverse events. Thus,
furthersubanalysiswasthoughttobewarrantedinthesethree TABLEXBreakdownofForty-sevenMedicationErrorsbythe
NCCMERPClassificationSystem*
areas(equipment,communication,andmedications).Wrong-
site surgery has been a special interest area of the AAOS for
NCCMERP No.(%) Harm
many years and also underwent subanalysis. Class Description ofCases Level†
Equipment Errors Subanalysis A Circumstancesorevents 2(4) 0
thathavethecapacityto
Equipmenterrors(29%ofallreportedincidents)wereinitially
causeerror
broken down into three primary subcategories. Instrumenta-
B Anerroroccurredbutthe 1(2) *
tion problems (63.2%) occurred approximately twice as fre-
errordidnotreachthe
quently as implant errors (31.6%). A further division of the
patient(An‘‘errorof
two high-frequency categories (instrumentation errors and
omission’’doesreach
implanterrors)was performed. thepatient)
In the secondary subanalysis of instrumentation errors,
C Anerroroccurredthat 9(19) *
technical use errors (29.6%) occurred most often. Examples reachedthepatientbutdid
include excessive tibial resection secondary to an improperly notcausethepatientharm
assembled cutting jig. Missing parts (28.6%) was almost as D Anerroroccurredthat 13(28) *
frequent.Onthenexttieroffrequencyweresterilityproblems reachedthepatientand
(16.4%)and intraoperativebreakage(14.3%). requiredmonitoringto
Regardingtheimpacttothepatientbyequipmenterrors, confirmthatitresultedinno
harmtothepatientand/or
surgery was cancelled in 11.6% of the cases, the surgical plan
requiredinterventionto
was altered in 16.8%, surgery was prolonged in 12.3%, and
precludeharm
reoperation was necessary in 8.4% of the cases. An extended
E Anerroroccurredthatmay 5(11) 1
‘‘orthopaedic time out’’ (checking allergies, antibiotics, rec-
havecontributedtoor
ords, imaging, and equipment) was estimated to have been resultedintemporaryharm
potentially able to detect a problem and prevent a medical tothepatientandrequired
error in approximately 16.8%of these cases. intervention
F Anerroroccurredthatmay 9(19) 1
Implant Errors Subanalysis havecontributedtoor
The implant-related error with the highest rate was missing resultedintemporaryharm
tothepatientandrequired
implants (42.9%). Having the wrong implant constituted
initialorprolonged
28.6% of the incidents. Less common problems were late ar-
hospitalization
rival (12.2%), an implant that broke intraoperatively (6.1%),
G Anerroroccurredthatmay 2(4) 1
and the implantthat brokepreoperatively (2.0%).
havecontributedtoor
resultedinpermanent
Communication Errors Subanalysis patientharm
The initial breakdown of communication errors was into five
H Anerroroccurredthat 4(9) 1
categoriesbytheformatofthecommunication.Incidentscould requiredintervention
tallytomorethanonecategory.Therewerecompoundinger- necessarytosustainlife
rorsinsomeincidents.Theincidentsinvolvedverbal(16.0%), I Anerroroccurredthatmay 2(4) #
written (29.1%), and dictated comments (0.7%). Errors in- havecontributedtoor
volved protocols already in place in 31.2% of the cases, and resultedinthepatient’sdeath
failuretocommunicateconstituted23.4%ofthecases.
The venue of communication errors was the hospital *Nineclasses(A throughI), ranking fromtheleastpotentialfor
(81.9%), rehabilitation unit or nursing home (4.7%), surgery patientharm(A)toanerrorcontributingtoapatientdeath(I).†The
harmlevelisbrokendownintofouradditionalsubcategories:0=
center(1.6%),andofficeorclinic(11.8%).Thehospitalvenue
categorieswherenoerroroccurredbuteventshadacapacityfor
wasfurthersubdividedintotheoperatingroom,includingthe
error,*=errorbutnoharm,1=errorwithharmtopatient,and#=
preoperativeholdingarea(35.5%);thepostanesthesiacareunit errorresultinginpatientdeath.
(2.9%);theintensivecareunit(1%);thesurgicalfloor(30.7%);
theradiologydepartment(9.6%);andthelaboratory(5.8%).
The medical personnel involved in communication er- acase),in15.7%.Floornurseswereassociatedwith16.4%of
rorsweretallied.Morethanoneprovidercouldbeinvolvedper theincidents;physicianassistants,with1.4%;officestaff,with
incident. The orthopaedic surgeon was involved in 24.3% of 10%; and pharmacists, with 3.6%. Industry representatives
the incidents and other physicians, in 16.5%. Nurses in the were involved with 5% of the communication errors.
operating room (not during an actual case) were involved in Atthepatientlevel,communicationerrorsresultedina
7.1%andcirculators,scrubnurses,and/ortechnicians(during nearmissin19.4%oftheincidents.Errorsreachingthepatient
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level but resulting in no harm were involved in 47.6% of the The impact of equipment-related errors on patients was
incidents. An error reached the patient level and caused a common,witheffectsreachingthepatientlevelin49.1%ofthe
negativeoutcomein33%oftheincidents.Thenegativeimpact incidents.Fortunately,mostconsequenceswereminor,andonly
topatientsvariedfromminordelaysofsurgerytorevisionknee 8.4%oftheeventsrequiredareoperation.Communicationer-
arthroplasty(whenawrong-sidedprosthesiswasimplanted). rorswerethesecondmostfrequenterror(24.7%).Asubanalysis
showedthelargestproportion(31.2%)occurredwhentherewas
Serious Medication Incidents Subanalysis (Table X) a ‘‘protocol in place,’’ such as radiographs not arriving for a
The last three categories (G, H, and I) of the NCC MERP scheduledsurgicalcase.Thesecondlargestcategorywas‘‘failure
classification15 of medication errors involve instances of per- tocommunicate’’(23.4%).Someoftheseoccurrencesmightbe
manent harm or death. In the AAOS study, eight patients addressed by strategies outside normal quality assurance pro-
(17%) fell into these categories (two died, four required in- grams. Failure to notify the surgeon that a wrong-sided knee
terventiontosustainlife,andtwosustainedpermanentharm). prosthesis passed onto the operating field may result from a
Both deaths occurred on the hospital ward and involved nar- hierarchical, sometimes intimidating, environment. ‘‘Crew re-
coticmedications.TwoofthepatientsintheHandIcategories source management’’ as developedintheaviation field17 could
were in the operating room. One sustained a cardiac arrest haveapplicationtothismedicalsituation18.
afterahighspinalanesthetic,andtheotherpatientsustaineda Verbal communication errors constituted 16% of the
cardiac arrest at the end of a procedure after receiving a final incidents. The JCAHO 2008 National Patient Safety Goals
dose of a supposedly epidural anesthetic and the nurse anes- specifyclearread-backonverbalorders19.Errorsresultingfrom
thetist had turned off the pulse oximeter alarms. written communication were involved in 29.1% of the inci-
dents. Creating an organizational culture with accurate com-
Wrong-Site Surgery Subanalysis munication(particularlywithmedicationadministration)has
Thereweretwenty-sevenincidentsofwrong-sitesurgery.Five been identified as an area requiring nursing, hospital, and/or
of these did not include sufficient detail for type subanalysis. pharmacy initiatives20-22.
The remaining twenty-two were broken down by type of Orthopaedicsurgeonswereinvolvedincommunication
wrong-sitesurgery.Themajority(59%)involvedthewrong errors 24.3% of the time. The AAOS has already embarked
side. However, there were also five instances (23%) of other onacommunicationskillsmentoringprograminconjunction
wrong location (e.g., the wrong finger on the correct hand), with the Institute for HealthcareCommunication (previously
threewrong procedures(14%), and one wrong patient (5%). theBayer InstituteforHealthcareCommunication)23,24.
Intermsofanatomiclocation,sevenofthetwenty-sevendid Itis disconcerting that wrong-site surgeries continue to
not have specific anatomic descriptions. The remaining twenty occur.The orthopaedicsurveywassent outtwomonthsafter
incidentswereclassifiedbyanatomicsite.Thekneeandthefingers the JCAHO Universal Protocol for Preventing Wrong Site,
and/or hand both accounted for the highest number of occur- Wrong Procedure, Wrong Person Surgery25-27 became manda-
rences(35%each).Thenextmostfrequentanatomiclocationwas tory. JCAHO statistics corroborated an ongoing incidence of
thefootandankle(15%).Thereweretwoincidentsofatraction wrong-site surgery28,29. These data led the JCAHO to convene
pinbeingplacedinthedistalendofthefemuronthewrongside another Wrong Site Surgery Summit29 on February 23, 2007.
(10%)andoneinstanceofspinesurgeryatthewronglevel(5%). The surgery team’s full and precise compliance with the Uni-
versal Protocol was identified as the major issue surrounding
Discussion the persistent occurrence of wrong site surgery29. Subanalysis
Population surveys have limitations. In this survey, re- found that the leading factor contributing to these incidents
sponses were received from a relatively low percentage of wascommunication problems (>60%)30.
thetargetpopulation.Inaddition,thereisapotentialforrecall The types and locations of wrong-site surgery in ortho-
biaswithaneventtimeframeofseveralmonths.Thesefactors paedicsmirrorthoseintheJCAHOanalysisforeventsinthe2006
limit confidence in the generalizability of population survey calendaryear29.Theerrorsinvolvedthewrongsidein59.1%of
results.Thus,webelievethattheappropriatelevelofutilityfor theincidentsinthepresentstudyand56%intheJCAHOstudy;
this study is for trending purposes to help to focus quality other wrong location, such as the wrong digit on the correct
assuranceeffortsandasamotivatorformoredetailedresearch. hand,in22.7%and19%,respectively;thewrongprocedure,in
In this survey of orthopaedic surgeons, the category of 13.6%and8%;andthewrongpatientin4.5%and17%.There
equipment-related errors had the highest rate of incidents is clearly a need for a diverse, systems approach to prevent
(29%),perhapsnotsurprisinggivenourtechnology-intensive medicalerrors.Onebarrier,suchastheinstitution ofa‘‘time
procedures. Communication errors had the second highest out’’intheoperatingroom,isinadequate.Multiplepreventative
rate (24.7%). These two categories constituted 53.7% of the systemsbarriersareneededtoavoiddiversetypesoferror.
total number of errors. This contrasts with a broader distri- Medicationerrorsarealsoanongoingsourceofconcern
butionfromtheear,nose,andthroatsurgerysurvey12,inwhich fororthopaedics31 and medicine in general. Medication errors
fourcategoriesmade up53.3%oftheerrors(technicalerrors represented9.7%oftheorthopaedicerrorreports.Inthissur-
atsurgerycomprised19.3%oftheerrors;medication,13.7%; vey,bothpatientdeathsattributabledirectlytoanerrorresulted
testing, 10.4%; and surgical planning, 9.9%). from medication errors involving narcotic administration on
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thehospitalward.AJCAHO2008NationalPatientSafetyGoal intheanalysisoferrorcategoriescanserveasaguidetoquality
is to ‘‘improve the safety of using medications.’’19 The NCC assuranceefforts.
MERP also has a focus on medication errors15. Computerized Theeliminationofwrong-sitesurgeryhasbeenapriority
order-entrysystemshavebeenexploredasapossiblestrategyfor oftheAAOSandsubspecialtysocietiesformorethanadecade
errorprevention32,andtheAAOShasanInformationStatement withtheAAOSSignYourSiteinitiative1and,morerecently,the
onPreventionofMedicationErrors31. North American Spine Society ‘‘Sign, Mark and X-Ray’’ pro-
Communicating medical errors topatientsand family is gram42. The JCAHO has mandated the Universal Protocol25,26,
controversial. The AAOS published an advisory statement in which includes the three elements of patient identification,
2004indicatingthatadverseeventsshouldbedisclosed‘‘directly surgicalsitemarking,andcalling‘‘timeout’’priortoincision.
withapatient/family member inanhonest,compassionate The latest Wrong Site Surgery Summit, convened by the
mannerassoonaspossibleafteranadverseeventoccurs.’’33 An JCAHO in February 2007, concluded that the Universal Pro-
articleintheAmericanMedicalNewsreportedthatseveralstates tocolwasawell-constructedpolicy29.However,effortsneeded
(California, Georgia, Massachusetts,Texas,andVermont) have to be redoubled to educate physicians, hospitals, and other
passed legislation ‘‘protecting statements or other benevolent health-careinstitutionsregardingtheunderlyingprinciplesof
gesturesexpressingsympathy frombeing admittedasevidence theprotocol.Inaddition,specificattentionneededtobepaid
ofliability inmedicalmalpracticeandotheraccidentcases.’’34 tothedetailsoftheprotocolbyallindividualsonthesurgical
In Colorado, the Colorado Physicians Insurance Corpo- team or wrong-site surgeries wouldcontinueto occur.
ration(COPIC),thephysician-ownedprofessionalliabilitycar- Leadershiphasbeenidentifiedasakeyfactorincreating
rier, has developed a novel program for dealing with adverse a culture of safety in medical practice43. In orthopaedics, pa-
events and medical errors35,36. Both the present COPIC Chief tient safety continues to be a high priority for the AAOS and
Executive Officer, Ted Clarke, MD, and his predecessor, K. membersoftheAAOSBoardofSpecialtySocieties,suchasthe
Mason Howard, MD, are orthopaedic surgeons. Dr. Howard North American Spine Society. The American volume of The
alsocoauthoredoneofthetwoarticles37,38thatformedthebasis Journal of Bone and Joint Surgery, as the premier respected
of the Institute of Medicine report To Err Is Human: Building journalintheorthopaedicspecialty,hashighlightedtheimpor-
a Safer Health System6. The COPIC 3R’s Program (Recognize, tance of patient safety in its editorial pages44 and Orthopaedic
Respond, Resolve) provides for ‘‘open and honest communica- Forumsection3,5,aswellaswiththepublicationofpeer-reviewed
tionwiththepatient,’’35includesphysiciantrainingfordisclosing papers45-47.
unanticipated outcomes, and provides no-fault compensa- DatafromtheAAOSPatientSafetySurveywillenhance
tionforapatient’sout-of-pocketexpenses(alimitof$30,000). theabilityoforthopaedicsurgeonstosafelylookafterpatients.
Patients are not required to sign documents stipulating that Further,theresultsofthesurveyserveasanindicatorforquality
they will not file a lawsuit. A summary of this program was assuranceefforts,pointtoareasofpotentialadditionalresearch,
publishedintheNewEnglandJournalofMedicine36.Following andhelptomaintaintheleadershiproleoforthopaedicsurgery
implementation, the number of expected lawsuits resulting increatinga‘‘cultureofsafety’’inmedicine.n
fromadverseeventswasreduced35,36.
NOTE:TheauthorsthankSylviaWatkins-CastilloandherstaffattheAAOSDepartmentofRe-
Physician attitudes and experience toward disclosing searchfortheirassistanceindisseminatingthesurveyandcollatingtheresponses.Theyalso
thankKatherineWongfromDenverSpinefororganizingtheequipmentandcommunication
errors to patients have been surveyed39. Patients arenot often subanalysis.
told of medical errors, particularly those that do not result in
harm. The largest barrier identified by physicians in both the
United Statesand Canadawas themalpracticeenvironment.
Dr. John Eisenberg, the late Director of the Agency for
DavidA.Wong,MD,MSc,FRCS(C)
Healthcare Research and Quality (AHRQ), was a strong ad-
DenverSpine,Suite100,7800EastOrchardRoad,
vocate for changing the present culture of ‘‘finger pointing’’ GreenwoodVillage,CO80111.E-mailaddress:[email protected]
(thename,blame,andshameapproach)andmovingtowarda
systems-orientedmethodologyforaddressingmedicalerrors40. JamesH.Herndon,MD
He believed that continuing educationwas the key to culture MassachusettsGeneralHospital,55FruitStreet,
White#542,Boston,MA02114
modification. Resistance to the adoption of patient safety
practices continues, however, even in circumstances in which
S.TerryCanale,MD
thereis good evidenceof effectiveness41.
CampbellFoundation,1211UnionAvenue,
In conclusion, medical errors continue to be a cause of Suite510,Memphis,TN38104
concern.Toourknowledge,theAAO-HNSandtheAAOSare
theonly two specialty medical societiesto conduct patient RobertL.Brooks,MD,PhD,MBA
safety surveys. The AAOS member survey has allowed an DelmarvaFoundationforMedicalCare,6940
ColumbiaGatewayDrive,Columbia,MD21046-2788
overview of the occurrence of errors within orthopaedics.
Equipment errors and communication errorsappear to be
ThomasR.Hunt,MD
themostfrequentlyobservedtypes,andmedicationerrorshad UniversityofAlabama,FOT930,51020thStreetSouth,
the most serious consequences for patients. Trends identified Birmingham,AL35294