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Medical Errors in OrthopaedicsResults of an AAOS Member Survey
David A. Wong, MD, MSc, FRCS(C)1; James H. Herndon, MD2; S. Terry Canale, MD3; Robert L. Brooks, MD, PhD, MBA4; Thomas R. Hunt, MD5; Howard R. Epps, MD6; Steven S. Fountain, MD7; Stephen A. Albanese, MD8; Norman A. Johanson, MD9
1 Denver Spine, Suite 100, 7800 East Orchard Road, Greenwood Village, CO 80111. E-mail address: ddaw@denverspine.com
2 Massachusetts General Hospital, 55 Fruit Street, White #542, Boston, MA 02114
3 Campbell Foundation, 1211 Union Avenue, Suite 510, Memphis, TN 38104
4 Delmarva Foundation for Medical Care, 6940 Columbia Gateway Drive, Columbia, MD 21046-2788
5 University of Alabama, FOT 930, 510 20th Street South, Birmingham, AL 35294
6 Fondren Orthopedic Group, 7401 South Main Street, Houston, TX 77030
7 Northern California Mutual, P.O. Box 5940, La Quinta, CA 92248
8 University of Upstate New York, 550 Harrison Street, Suite 128, Syracuse, NY 13202
9 Drexel University College of Medicine, 245 North 15th Street, Room 7209, Philadelphia, PA 19096
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM/DVD (call our subscription department, at 781-449-9780, to order the CD-ROM or DVD).

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Mar 01;91(3):547-557. doi: 10.2106/JBJS.G.01439
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Background: There has been widespread interest in medical errors since the publication of To Err Is Human: Building a Safer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy of Orthopaedic Surgeons has compiled the results of a member survey to identify trends in orthopaedic errors that would help to direct quality assurance efforts.

Methods: Surveys were sent to 5540 Academy fellows, and 917 were returned (a response rate of 16.6%), with 53% (483) reporting an observed medical error in the previous six months.

Results: A general classification of errors showed equipment (29%) and communication (24.7%) errors with the highest frequency. Medication errors (9.7%) and wrong-site surgery (5.6%) represented serious potential patient harm. Two deaths were reported, and both involved narcotic administration errors. By location, 78% of errors occurred in the hospital (54% in the surgery suite and 10% in the patient room or floor). The reporting orthopaedic surgeon was involved in 60% of the errors; a nurse, in 37%; another orthopaedic surgeon, in 19%; other physicians, in 16%; and house staff, in 13%. Wrong-site surgeries involved the wrong side (59%); another wrong site, e.g., the wrong digit on the correct side (23%); the wrong procedure (14%); or the wrong patient (5% of the time). The most frequent anatomic locations were the knee and the fingers and/or hand (35% for each), the foot and/or ankle (15%), followed by the distal end of the femur (10%) and the spine (5%).

Conclusions: Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance efforts and more refined research can be addressed toward areas with higher error occurrence (equipment and communication) and high risk (medication and wrong-site surgery).

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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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    Sukhmeet S Panesar
    Posted on July 24, 2009
    Orthopaedics – Matching Precision with Safety
    National Patient Safety Agency, London, United Kingdom

    To the Editor:

    We welcome the article by Wong et al. (1) which has made a great contribution to the literature on patient safety in orthopaedic surgery. Similarly, across the Atlantic, key advances are being made to understand patient safety. We are privileged to have the existence of the National Patient Safety Agency (NPSA). The Department of Health (UK) has been spearheading the patient safety agenda through the creation of the NPSA which has led to the development of the Reporting and Learning System (RLS) database of patient safety incidents which are reported by all the hospitals in England and Wales (2). Running since 2003, this database is now the largest of its kind in the world, already having received over three million reports of episodes of care that could or did result in iatrogenic harm (3). Undoubtedly, the database has its limitations owing to its nature of being a self-reporting, voluntary system with a blame-free culture. There is a also a great deal of under-reporting. However, important nuggets of information can be obtained.

    The largest proportions of these patient safety incidents originate from medical specialties (34%), surgical specialties (15%), mental health (13%) and obstetrics and gynecology (10%).

    Our top categories of patient safety incidents reported in trauma and orthopaedic surgery include patient accident (which includes collision with objects, contact with sharps, inappropriate patient handling or positioning and slips, trips and falls). These account for 18490/47229 (39.1%) incidents. Treatment and procedure account for 6960/47229 (14.7%), medication account for 3790/47229 (8.02%) and infrastructure (staffing, facilities and environment) account for 3183/47229 (6.7%) of the total burden of patient safety incidents.

    We are trying to shift the paradigm of our database, which skeptics believe is limited, to warning, communication and detection of rare patient safety incidents such as bone cement implantation syndrome (4,5).

    Our specialty demands the utmost expertise in treating insult to bone and the modern era demands that we apply the same expertise in understanding and mitigating against errors that could occur in trauma and orthopaedic surgery.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.


    1. 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;91:547-57.

    2. Department of Health. High quality care for all: NHS Next Stage Review final report. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825. Accessed 2009 Jul 16.

    3. National Patient Safety Agency National Reporting and Learning Service. Patient safety incident reports in the NHS: National Reporting and Learning System Data Summary. Issue 11 (Feburary 2009) - ENGLAND. http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=26473. Accessed 2009 Jul 24.

    4. Vincent C, Aylin P, Franklin BD, Holmes A, Iskander S, Jacklin A, Moorthy K. Is health care getting safer? BMJ. 2008;337:a2426.

    5. National Patient Safety Agency Rapid Response Reports. Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur. March 11, 2009. http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/mitigating-risks-when-using-bone-cement-in-hip-surgery/. Accessed 2009 Jul 24.

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