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Editorial   |    
The Patient First. Above All Do No Harm (Primum Non Nocere)
James H. Herndon, MD
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Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Feb 20;95(4):289-290. doi: 10.2106/JBJS.9504edit
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No caring and responsible physician or surgeon knowingly wants to harm a patient…to be responsible for a medical or surgical error…yet now, more than twelve years after the Institute of Medicine’s report drawing national attention to errors, the incidence of errors and reported harm to patients continues1. Every physician and surgeon should ask themselves why, and they should feel obligated to avoid medical and surgical mistakes in their practices and hospitals.
To date, altruism and professionalism haven’t worked, pay-for-performance programs haven’t worked, and regulations haven’t worked2. Estimates of avoidable injuries and deaths remain unchanged or are increasing, and readmissions remain unchanged at 15% to 24%3. Hospitals only voluntarily report errors, and these reports yield an error rate of about 1%. However, using a global trigger tool, the Institute of Healthcare Improvement estimates that the rate of adverse events is ten times the voluntarily reported rate4. Except in hospitals that strictly enforce a preoperative time-out and require the surgeon to sign the correct surgical site, the incidence of wrong-site surgery is increasing5. Why do we keep doing the same things over and over again and expect a different result?
Lucian Leape believes that there has been some progress in the patient safety movement6. We now have safe practices for both process and system issues, but he asks what is missing today in attempts to improve patient safety. “Why can’t we stop wrong-site surgery?” “Why don’t hospitals have 100% compliance with hand washing?” He believes, as I do, that patient safety is a moral issue…When a physician is wrong, someone else is hurt. There is no accountability. Leape states, “We are not going to get safe care until we want to see it happen.” Nevertheless, 56% of physicians believe that quality of care will decrease under current health-care reform7. Why do they think this, if the patient comes first and harm is to be avoided?
Atul Gawande has reported that deaths from surgical errors have decreased from 1.5% to only 1.2% since 2002 (unpublished data)8. This represents about 50,000 deaths per year in the United States. He states that the major reasons for this change are improvements in technique, use of minimally invasive procedures, use of protocols, improved communication, and, most importantly in his opinion, the frequent mitigation of operating-room disasters in modern intensive care units with specialty-trained personnel. The best hospitals have the best rescue rates. Gawande has demonstrated the benefits to patient safety of the use of checklists in hospitals in the United States and other countries. The reported use of surgical checklists has reduced deaths due to errors from 1.5% to 0.8% and inpatient complications from 11% to 7.0%9.
In October 2012, the National Association for Healthcare Quality released a report entitled “Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems.”10 In the report, they called for four actions: (1) establish accountability for the integrity of quality and safety systems, (2) protect those who report quality and safety findings, (3) report quality and safety data accurately, and (4) respond to quality and safety concerns with robust improvement. Such calls should be implemented by orthopaedic surgeons, by our professional organizations such as the AAOS (American Academy of Orthopaedic Surgeons), AOA (American Orthopaedic Association), ABOS (American Board of Orthopaedic Surgery), RRC (Residency Review Committee), and specialty societies; by hospitals and ambulatory surgery centers; and by insurers as well as by legislative and regulatory bodies.
The emphasis in the patient safety movement has been increasingly directed at systems issues, with few reports emphasizing individual mistakes and responsibility. In his early (1908) error classification system, Codman included system issues, although he did not differentiate them from errors related to individuals11. However, Codman emphasized the following individual errors, which remain important for surgeons: lack of technical skill or knowledge, lack of surgical judgment, lack of diagnostic skill, and lack of care. In this issue of JBJS, Matsen et al. report that these same four individual errors listed by Codman continue to be largely responsible for malpractice claims against orthopaedic surgeons…104 years later. Wong et al. also reported that, according to an AAOS member survey, orthopaedic surgeons are involved in 60% of reported errors12.
Patient safety through reduction of surgical errors continues to be of major importance to patients and all health-care providers. It remains a major concern that progress has been slow and minimal. It is difficult to predict how the needed changes to the culture will occur. However, I believe that increased leadership by physicians and our professional organizations is needed, combined with a true partnership with our patients. We must support disclosure and reporting of all errors, development of national registries, root cause analyses of errors (such as wrong-site surgery), computerized skills tests to assess fatigue in surgeons before they perform an operation, remedial training (including coaching programs) for those surgeons with high rates of errors or complications as well as for disruptive physicians, assessment and remedial training of surgeons with hazardous attitudes, use of surgical checklists, identification and reduction of unnecessary surgery and overuse of specific procedures, acceptance of clinical guidelines and appropriate use criteria, and other efforts to improve patient safety.
The list is long. Barriers to our success in improving our patients’ safety are substantial and include the lack of medical liability reform and fear that disclosure of our mistakes will have consequences such as potential loss of patients or income as well as public embarrassment. To be successful, I believe that we have to partner with our professional organizations, our patients, The Joint Commission, the American College of Surgeons (and other physician organizations), the ABOS (and other boards), the Accreditation Committee for Graduate Medical Education, the Centers for Medicare & Medicaid Services, insurers, and state and federal legislators. It is a huge task. Change will not be quick, but will be slow and difficult. However, change is essential.
Institute of Medicine. To err is human: building a safer health system. Washington: National Academic Press; 1999.
 
Jha  AK;  Joynt  KE;  Orav  EJ;  Epstein  AM. The long-term effect of premier pay for performance on patient outcomes. N Engl J Med.  2012 Apr 26;366(  17):1606-15.[CrossRef]
 
Joynt  KE;  Jha  AK. Thirty-day readmissions–truth and consequences. N Engl J Med.  2012 Apr 12;366(  15):1366-9.  Epub 2012 Mar 28.[CrossRef]
 
Classen  DC;  Resar  R;  Griffin  F;  Federico  F;  Frankel  T;  Kimmel  N;  Whittington  JC;  Frankel  A;  Seger  A;  James  BC. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood).  2011 Apr;30(  4):581-9.[CrossRef]
 
Pennsylvania Patient Safety Advisory.  Quarterly Update on Preventing Wrong-Site Surgery. 2012 Sep. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Sep;9(3)/Pages/111.aspx. Accessed 2012 Mar 9.
 
Leape  L,  Harvard School of Public Health. Personal communication; 2012 Jun 26.
 
The Physician Foundation.  Health Reform Survey. 2010 Oct 12. http://www.physiciansfoundation.org/focus-areas/health-reform-survey-2010/.
 
Gawande  A,  Brigham and Women’s Hospital and Harvard Medical School. Personal communication; 2012 Jul 26.
 
Haynes  AB;  Weiser  TG;  Berry  WR;  Lipsitz  SR;  Breizat  AH;  Dellinger  EP;  Herbosa  T;  Joseph  S;  Kibatala  PL;  Lapitan  MC;  Merry  AF;  Moorthy  K;  Reznick  RK;  Taylor  B;  Gawande  AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med.  2009 Jan 29;360(  5):491-9.[CrossRef]
 
National Association for Healthcare Quality.  Call to action. Safeguarding the integrity of healthcare quality and safety systems. 2012 Oct. http://www.nahq.org/uploads/NAHQ_call_to_action_FINAL.pdf. Accessed 2012 Oct 16.
 
Codman  EA.  A study in hospital efficiency: as demonstrated by the case reports of the first five years of a private hospital. Boston: Thomas Todd Co; 1918.
 
Wong  DA;  Herndon  JH;  Canale  ST;  Brooks  RL;  Hunt  TR;  Epps  HR;  Fountain  SS;  Albanese  SA;  Johanson  NA. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am.  2009 Mar 1;91(  3):547-57.[CrossRef]
 

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References

Institute of Medicine. To err is human: building a safer health system. Washington: National Academic Press; 1999.
 
Jha  AK;  Joynt  KE;  Orav  EJ;  Epstein  AM. The long-term effect of premier pay for performance on patient outcomes. N Engl J Med.  2012 Apr 26;366(  17):1606-15.[CrossRef]
 
Joynt  KE;  Jha  AK. Thirty-day readmissions–truth and consequences. N Engl J Med.  2012 Apr 12;366(  15):1366-9.  Epub 2012 Mar 28.[CrossRef]
 
Classen  DC;  Resar  R;  Griffin  F;  Federico  F;  Frankel  T;  Kimmel  N;  Whittington  JC;  Frankel  A;  Seger  A;  James  BC. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood).  2011 Apr;30(  4):581-9.[CrossRef]
 
Pennsylvania Patient Safety Advisory.  Quarterly Update on Preventing Wrong-Site Surgery. 2012 Sep. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Sep;9(3)/Pages/111.aspx. Accessed 2012 Mar 9.
 
Leape  L,  Harvard School of Public Health. Personal communication; 2012 Jun 26.
 
The Physician Foundation.  Health Reform Survey. 2010 Oct 12. http://www.physiciansfoundation.org/focus-areas/health-reform-survey-2010/.
 
Gawande  A,  Brigham and Women’s Hospital and Harvard Medical School. Personal communication; 2012 Jul 26.
 
Haynes  AB;  Weiser  TG;  Berry  WR;  Lipsitz  SR;  Breizat  AH;  Dellinger  EP;  Herbosa  T;  Joseph  S;  Kibatala  PL;  Lapitan  MC;  Merry  AF;  Moorthy  K;  Reznick  RK;  Taylor  B;  Gawande  AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med.  2009 Jan 29;360(  5):491-9.[CrossRef]
 
National Association for Healthcare Quality.  Call to action. Safeguarding the integrity of healthcare quality and safety systems. 2012 Oct. http://www.nahq.org/uploads/NAHQ_call_to_action_FINAL.pdf. Accessed 2012 Oct 16.
 
Codman  EA.  A study in hospital efficiency: as demonstrated by the case reports of the first five years of a private hospital. Boston: Thomas Todd Co; 1918.
 
Wong  DA;  Herndon  JH;  Canale  ST;  Brooks  RL;  Hunt  TR;  Epps  HR;  Fountain  SS;  Albanese  SA;  Johanson  NA. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am.  2009 Mar 1;91(  3):547-57.[CrossRef]
 
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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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James H. Herndon, MD
Posted on March 05, 2013
Participation in national registries
Massachusetts General Hospital and Harvard Medical School

I agree with Dr. Dohm that it is time for orthopaedic surgeons and our professional organizations to improve patient safety/quality by participating in national registries…with their patient's outcomes, by providing leadership and providing financial support. Many western countries have joint registries, but United States registries remain in their infancy, without full participation by all stakeholders.

Michael Dohm, MD
Posted on February 23, 2013
Patient Safety and applications of evidence to orthopaedic practice.
Western Slope Study Group

I appreciate Dr. Herndon's comments. Florence Nightingale RN and Ernest Amory Codman MD* were both interested in patient safety and patient outcomes in the late 19th and early 20th centuries. 100 years later we are still trying to improve our quality of orthopaedic care, reduce the number of adverse events, increase the level of patient safety and work toward the goal of best practice. I, like many others, believe it is time to move forward with a substantial coordinated effort to establish and support an outcomes structure which should be promoted and nurtured by our orthopaedic societies. Projects like the American Joint Replacement Registry, the International Society of Arthroplasty Registers, and the North American Spine Society Registry are all a good attempt at collaboration. We as orthopaedic surgeons are clinical scientists and it is our responsibility to participate in these endeavors. The internet allows us the opportunity to engage in these activities in an efficient and effective fashion. The pillars of our American Academy of Orthopaedic Surgeons are education, research and advocacy. I submit that the true foundation of advocacy lies in reproducible and reliable data. The time for participation is now.

* Mallon, Bill (2000). Ernest Amory Codman: The End Result of a Life in Medicine. Philadelphia: WB Saunders. ISBN 0-7216-8461-0.

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