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Lessons Regarding the Safety of Orthopaedic Patient CareAn Analysis of Four Hundred and Sixty-Four Closed Malpractice Claims
Frederick A. Matsen, III, MD1; Linda Stephens, PhD2; Jocelyn L. Jette, BS1; Winston J. Warme, MD1; Karen L. Posner, PhD2
1 Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 NE Pacific Street, Seattle, WA 98195-6500. E-mail address for F.A. Matsen III: matsen@u.washington.edu
2 Department of Anesthesiology and Pain Medicine, University of Washington, Box 356540, Seattle, WA 98195-6540
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Investigation performed at the University of Washington, Seattle, Washington, under the auspices of the Washington State Orthopaedic Association

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her 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. No author has had any other relationships, or has 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):e20 1-8. doi: 10.2106/JBJS.K.01272
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An orthopaedic malpractice claim alleges that the patient sustained a preventable iatrogenic injury. The analysis of a representative series of malpractice claims provides a unique view of alleged orthopaedic adverse events, revealing what can potentially go wrong across a spectrum of practice settings and anatomic locations. The goal of this study was to identify high-impact targets in order to institute measures to reduce claims through efforts focused on patient safety.


The authors investigated 464 consecutive closed malpractice claims from the nation’s largest insurer of medical liability. We analyzed the claims by anatomical site, type of care rendered, type of allegation, and payment. We calculated an “impact factor” for each claim type by dividing the percentage of total payments for each type by the percentage of total claims for that type.


Our analysis revealed major concerns regarding patient safety within this series of malpractice claims. One-third of the claims alleged permanent disabling injuries, including amputations, brain damage, and major nerve damage. The highest impact allegations were failure to protect structures in the surgical field (41% of total payments to plaintiffs, 15% of all claims, impact factor of 2.7) and failure to prevent, diagnose, and/or treat complications of treatment (16% of total payments, 7% of all claims, impact factor of 2.3). Spine procedures had high impact (1.9), representing 28% of dollars paid and 15% of claims, with 45% of spine claims involving death or severe permanent injury. Failure of implant positioning was commonly alleged in hip and knee arthroplasty. In claims related to fracture care, the most common allegations were related to malunions, nonunions, dislocations, failure to protect structures in the surgical field, infection, and treatment complications. Total payment for the eighty-eight claims paid was $17,917,614 (U.S. dollars adjusted to 2009).


Regarding clinical relevance, this analysis suggests risk areas for targeted efforts to improve patient safety and reduce malpractice claims.

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    Accreditation Statement
    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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