TY  - JOUR
T1  - Medical Errors in OrthopaedicsResults of an AAOS Member Survey
AU  - Wong, David A.
AU  - Herndon, James H.
AU  - Canale, S. Terry
AU  - Brooks, Robert L.
AU  - Hunt, Thomas R.
AU  - Epps, Howard R.
AU  - Fountain, Steven S.
AU  - Albanese, Stephen A.
AU  - Johanson, Norman A.
Y1  - 2009/03/01
N1  - 10.2106/JBJS.G.01439
JO  - The Journal of Bone & Joint Surgery
SP  - 547
EP  - 557
VL  - 91
IS  - 3
N2  - 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).
SN  - 0021-9355
M3  - doi: 10.2106/JBJS.G.01439
UR  - http://dx.doi.org/10.2106/JBJS.G.01439
ER  -