Medical Errors in Orthopaedics - AAOS Errors in Orthopaedics. ... medical societies in proactively confronting issues of medical er- ... from regulatory agencies and another surgical

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2009;91:547-557. doi:10.2106/JBJS.G.01439 J Bone Joint Surg Am.Steven S. Fountain, Stephen A. Albanese and Norman A. Johanson David A. Wong, James H. Herndon, S. Terry Canale, Robert L. Brooks, Thomas R. Hunt, Howard R. Epps,

Medical Errors in Orthopaedics. Results of an AAOS Member Survey

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Medical Errors in OrthopaedicsResults of an AAOS Member Survey

By David A. Wong, MD, MSc, FRCS(C), James H. Herndon, MD, S. Terry Canale, MD, Robert L. Brooks, MD, PhD, MBA,Thomas R. Hunt, MD, Howard R. Epps, MD, Steven S. Fountain, MD, Stephen A. Albanese, MD, and Norman A. Johanson, MD

Background: There has been widespread interest in medical errors since the publication of To Err Is Human: Building aSafer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy ofOrthopaedic Surgeons has compiled the results of a member survey to identify trends in orthopaedic errors that wouldhelp 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 thehighest 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 thehospital (54% in the surgery suite and 10% in the patient room or floor). The reporting orthopaedic surgeon was involvedin 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 theknee 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 assuranceefforts and more refined research can be addressed toward areas with higher error occurrence (equipment andcommunication) and high risk (medication and wrong-site surgery).

The Patient Safety Committee of the American Academy ofOrthopaedic Surgeons (AAOS) has recently completedan analysis of a membership survey regarding medical er-

rors in orthopaedic practice. The results were sought primarilyto assist ongoing, day-to-day efforts of the AAOS fellowship tokeep patients safe. An additional benefit was to help the PatientSafety Committee and the Academy leadership to identify andprioritize patient safety issues.

The research questions framed for the survey were:

� Will a member survey show occurrence of medicalerrors in orthopaedic practice?

� Do wrong-site surgeries continue to occur despite theAAOS Sign Your Site program and the Joint Commission onthe Accreditation of Healthcare Organizations (JCAHO) Uni-versal Protocol?

� Do medical errors in orthopaedics map to recognizederror classification systems?

� Can trends that might assist in focusing orthopaedicquality assurance efforts be identified?

The AAOS has been a recognized leader among professionalmedical societies in proactively confronting issues of medical er-rors and patient safety1-3. The first major safety initiative under-taken addressed wrong-site surgery. The AAOS Wrong SiteSurgery Task Force published its revised report in 19984. Theresulting voluntary program was christened the ‘‘Sign YourSite’’ or ‘‘SYS’’ initiative. As a voluntary program, Sign YourSite was not fully embraced by the Academy fellowship5.

The 2000 publication of the Institute of Medicine reportentitled To Err Is Human: Building a Safer Health System6 rep-resents the seminal event stimulating widespread interest in

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 oftheir 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 oursubscription department, at 781-449-9780, to order the CD-ROM or DVD).

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COPYRIGHT � 2009 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2009;91:547-57 d doi:10.2106/JBJS.G.01439

medical errors in the eyes of the public, news media, politicians,and the medical profession. The Institute of Medicine’s con-clusion that between 44,000 and 98,000 patient deaths per yearresulted from medical errors in hospitals in the United Stateswas widely publicized. As a result, patient safety has become anoteworthy issue in many quarters.

To date, meaningful data on medical errors have comefrom regulatory agencies and another surgical subspecialty so-ciety. The regulatory agency with the most experience analyzingmedical errors is probably the Joint Commission on the Ac-creditation of Healthcare Organizations (JCAHO). At the timeof publication of To Err Is Human, the JCAHO was alreadylooking at some specific errors (i.e., medication errors andwrong-site surgery) by means of its Sentinel Events program7,8.Other sentinel events (e.g., patient death) may have errorsidentified during the ‘‘Root Cause Analysis’’ required for everysentinel event. In addition to tabulating the incidence of sen-tinel events, the JCAHO developed a Patient Safety EventTaxonomy for additional subanalysis of medical errors9. Thistaxonomy system has been adopted by the National QualityForum (NQF)10. The NQF is a public-private partnered, not-for-profit organization ‘‘created to develop and implement anational strategy for health care quality measurement and re-

porting.’’11 The JCAHO-NQF taxonomy (Fig. 1) thus has wideacceptance and potential application.

The other professional medical society to publish a patientsafety membership survey involves ear, nose, and throat surgery 12

under the auspices of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). A general classificationsystem of medical errors was developed by those authors afterreview of the otolaryngology data (Table I). The ear, nose, andthroat surgery classification was used for broad analysis of theorthopaedic survey. This allows some general comparisons oferrors between physician subspecialty surgical groups.

Drug-related errors have been a particular interest area in thepopular press13 and a focus of quality assurance efforts in hospi-tals14. The National Coordinating Council for Medication ErrorReporting and Prevention (NCC MERP) has developed a classi-fication system of medication errors on the basis of the degree ofseriousness and/or harm (the potential for fatal error)15. There arenine categories (A to I). The potential for harm ranges from A(‘‘Circumstances or events that have the capacity to cause error,’’e.g., information on allergies unavailable for an unconscioustrauma victim) to I (‘‘An error occurred that may have contributedto or resulted in the patient’s death’’). Both direct patient deaths inthe AAOS survey were associated with medication errors. It was

Fig. 1

The Joint Commission on the Accreditation of Healthcare Organizations-National Quality Forum (JCAHO-NQF)

Classification of Medical Errors. Errors are primarily analyzed through each of five nodes (impact, type, domain,

cause, and prevention or mitigation). Each primary node has further subclassification options on descending

levels (secondary, tertiary, and quaternary). The example illustrated is the subclassification of an incident

that occurs in the hospital setting (the primary node is domain, the secondary node is setting, the tertiary

node is hospital, and the quaternary node is emergency room, operating room, intensive care unit, and

nursing unit).

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 91-A d NU M B E R 3 d M A R C H 2009ME D I C A L E R R O R S I N ORT H O PA E D I C S

therefore thought appropriate to break down the orthopaedicmedication errors with use of the NCC MERP system.

Materials and Methods

An orthopaedic medical errors survey was developed by theAAOS Patient Safety Committee with the assistance of

the AAOS Department of Research and consultation from themarketing research firm Axxiom Healthcare Alliance. The or-thopaedic survey was based on the ear, nose, and throat surgeryinstrument previously reported by Shah et al.12, with minorspecialty-specific modifications. The AAOS Department of Re-search engaged Axxiom Healthcare Alliance to assist in thefeasibility and pilot testing from which the orthopaedic surgery-adapted version of the survey was produced. This early criticalincident research confirmed the hypothesis or research questionthat medical errors were occurring in orthopaedics, thus sug-gesting that a wider survey would be worthwhile and applicableto orthopaedic clinical practice. Responses also indicated thatestablished classification systems, such as the ear, nose, andthroat surgery general classification12, the JCAHO-NQF rootcause taxonomy9,10, and the NCC MERP medication error clas-sification15, were likely appropriate for mapping the data.

The first phase pilot (twenty-four subjects) was admin-istered by Axxiom staff (to reduce bias) by means of a telephoneinterview. Subsequently, a focus group was convened at the 2004

AAOS Annual Meeting for a face-to-face description of criticalincidents and question feedback (again administered by Ax-xiom staff).

The pilot group was initially chosen according to age andpractice status (resident, member from thirty-five to forty-nineyears old, member over fifty years old, or emeritus fellow). Thegroup included representation from different practice settings(academic or private and urban or more rural), although thiscriterion was not a specific factor for inclusion. Orthopaedicnurses were also part of the critical incident pilot, but it wasultimately decided to survey physicians only (similar to the ear,nose, and throat study). The time frame for error was more open-ended in the pilot as we were primarily interested in the richness ofthe responses and therefore the reliability of the scripted ques-tions, which ultimately helped to refine the survey. The feedbacksuggested that patient-safety questions were understandable andanswered reliably by all segments of the membership. Axxiomthought that the thirty-five to forty-nine-year age group providedmore detailed responses in the open-ended description portion ofthe questioning. Rich responses were obtained from all groups.No en face differences were noted according to member status,age, or practice situation. Given these circumstances, the limitedavailable funding, and consideration of the fact that the surveyresearch questions were directed to the occurrence and/or clas-sification level rather than to therapeutics or clinical intervention,it was thought that we could distribute the survey according to thestandard mailing protocol in place at the AAOS Department ofResearch without further division, and a formal statistical analysisof internal consistency was not performed.

The survey used the same operational definition of medicalerror as that in the ear, nose, and throat instrument12 per Doveyet al.16. ‘‘Anything that has happened anywhere in your practice(office, hospital, operating room, emergency room, etc.) thatwas not anticipated, should not have happened, and makes yousay ‘I don’t want this to happen again’. It can be small or large,administrative or clinical—anything that you feel could beavoided in the future.’’

The definition was printed at the beginning of the survey.The Dovey interpretation is recognized as a broad, very inclu-sionary characterization of medical error. The potential forblurring the line between a complication and a medical error isrecognized. However, it was decided to use the same definition asthe ear, nose, and throat surgery survey for consistency. The timeframe for reporting of medical errors was also chosen to reflectthe ear, nose, and throat surgery instrument (six months).

On the orthopaedic survey instrument, the error definitionwas followed by six inquiries if an error was reported. These arespecifically outlined in the Results section (questions 1 through6). The response format for these questions was multiple choice(some using ‘‘all that apply’’ so that responses could fall intomultiple categories) followed by a write-in space for ‘‘other.’’ Themultiple choice options and the responses for each question areoutlined in Tables II through VII.

The respondent was then asked to insert a narrativedescription of the event in a blank space. No patient-specificdata were requested.

TABLE I The Ear, Nose, and Throat Surgery Classification

System Comprising Sixteen General Categories of

Medical Errors

Distribution of Errors*

Ear, Nose, and ThroatSurgery Classification12

Ear, Nose,and Throat

Surgery (N = 212)

OrthopaedicSurgery

(N = 483)

History and physical 1.4% 1.2%

Differential diagnosisor final diagnosis

1.4% 3.3%

Testing 10.4% 1.4%

Surgical planning 9.9% 1.7%

Wrong-site surgery 6.1% 5.6%

Anesthesia-related 3.3% 0.6%

Drug on surgical field 3.8% 0.0%

Technical 19.3% 13.0%

Retain foreign body 0.9% 1.2%

Equipment-related 9.4% 29.0%

Postoperative care 8.5% 3.9%

Medication errors 13.7% 9.7%

Nursing and/or ancillary 0.5% 3.9%

Administrative 6.6% 2.9%

Communication 3.8% 24.7%

Miscellaneous 0.9% 15.7%

*Errors may map to more than one category in the AAOS survey.

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The survey was sent to a cohort from the AAOS mailing list(5540 of the total membership of approximately 20,000) by theAAOS Department of Research. The members surveyed wereidentified by the Department of Research according to protocolsin place to distribute surveys evenly across the AAOS mailinglist (with a view to limit the burden of individual members torespond to frequent requests). The survey was forwarded inAugust 2005. Responses were accepted until the end of the year.

Responses included no patient-specific information. Infor-mation was collated by the AAOS Department of Research.Data were mapped primarily by the three classification systemspreviously specified (ear, nose, and throat surgery generalclassification; JCAHO-NQF root cause taxonomy system; andNCC MERP classification for drug errors). The responsesgenerally were classified directly, but the research departmentstaff identified some situations for which clinical input wasrequested to confirm mapping to a classification category. Forexample, in the NCC MERP analysis of drug errors, categori-zation was clear if a death had resulted, but, for some descrip-tions, the research staff wanted clinical input into whether anerror fell into the ‘‘no harm’’ or ‘‘temporary harm’’ categories. Aclassification task force (the Director of the Department ofResearch, the Chairman of the Patient Safety Committee, andan AAOS past president with specific interest and expertise in

patient safety) reviewed the raw data and/or categorization andconfirmed the final classification. A modified Delphi consensusmethodology was used. Equipment and communications taskforces (four-person subcommittees of the Patient Safety Com-mittee) similarly reviewed the data and confirmed the classifi-cations in these subdivisions. Incidents could tally in severalsubcategories, resulting in variable numerators and denomi-nators. Reporting is thus primarily expressed with use of per-centages (in similar fashion and allowing general comparison tothe ear, nose, and throat surgery survey).

Ear, Nose, and Throat Surgery General ErrorClassification SystemA general error classification system was developed by Shah et al.12

from the ear, nose, and throat surgery survey. Sixteen categories(Table I) were used to subclassify incidents. The system is generalin scope. Errors were broken into broad categories such as errorsin diagnosis, medical management, equipment, and wrong-sitesurgery.

JCAHO-NQF Error Classification SystemThis is a more detailed system developed from experience ofJCAHO9,10 in evaluating root cause analyses in the Sentinel Eventsprogram. The system is multitiered (primary, secondary, tertiary,and quaternary levels) and appears similar to a decision-tree al-gorithm (Fig. 1). Each error is initially mapped through five pri-mary nodes (impact, type, domain, cause, and prevention ormitigation). At each subsequent level, assigning the incident to acategory leads to further subclassification on the next level down.

TABLE II At What Stage in the Care Cycle Did This

Incident Occur?

Diagnosis 7%

Preintervention 7%

Intervention (treatment or surgery) 61%

Postintervention (follow-up care) 16%

From tests 3%

Other 3%

Unknown or no response 3%

TABLE III Where Did This Incident Occur?

Office 8%In-office surgery 1%Other in-office incident 7%

Hospital 78%Surgery 54%Patient room or nursing unit 10%Emergency room 6%Unknown 2%Ambulatory care 2%Other area 2%Laboratory 1%Rehabilitation 1%

Ambulatory care center 7%

Long-term-care facility 1%

Other facility 2%


TABLE IV Who Was Involved in This Incident?*

Myself 60%

Nursing staff 37%

Another orthopaedic surgeon 19%

Another physician (nonorthopaedic) 16%

Intern or resident 13%

Radiology 7%

Nurse practitioner or physician assistant 5%

Laboratory technician 2%

Pharmacy 2%

Therapist 1%

Other support personnel 23%Surgical or operating-room technician 4%Manufacturer’s representative 3%Administration 2%Equipment manager and/or management 2%Anesthesiologist 1%Assistants (SA, CRNA, etc.) 1%Patient or patient family 1%Other caregiver 1%Miscellaneous 1%

*Multiple responses were accepted. SA = surgical assistant, andCRNA = certified registered nurse anesthesiologist.

550



A number is assigned to the options in each layer of subclas-sification. Frequency data can be ascertained for each categoryat the various levels of analysis. A period is placed between thenumbers assigned at each level of classification. A wrong-sitesurgery occurring in the hospital operating room (classifica-tion 3.01.01.05) is categorized through the tier of options asfollows (Fig. 1):

� Primary node: domain (3)� Secondary options: setting (3.01)� Tertiary option: hospital (3.01.01)� Quaternary option: operating room (3.01.01.05)

Such a system is useful for investigators delving into themore detailed analysis of root cause issues.

Role of FundingThere was no external funding for this study.

Results

Of the 5540 surveys, 917 were returned (a response rate of16.6%). The response rate in the ear, nose, and throat sur-

gery survey12 (18.6%) was similar. Of the 917 orthopaedic surgeonrespondents, 483 (53%) had noted a medical error in the previoussix months.

There were six primary questions in the survey instru-ment for each reported incident:

1. At what stage in the care cycle did this incident occur?(Table II)

Treatment or surgery had the highest percentage (61%)followed by postintervention or follow-up care (16%).

2. Where did this incident occur? (Table III)The most frequent location was the hospital (78%). The

office (8%) and ambulatory care center (7%) were the locationof a smaller number of incidents.

3. Who was involved in this incident? (Select all thatapply) (Table IV)

Between the reporting orthopaedic surgeon (60%) andother orthopaedic surgeons (19%), AAOS fellows were involvedin almost all of the reported incidents. Nursing staff (37%) werethe next most frequent, followed by nonorthopaedic physicians(16%) and interns and residents (13%).

4. How would you classify this event? (Select all thatapply) (Table V)

Communication failure and equipment and/or instru-ment problems were clearly the high-frequency categories.

5. What was the outcome of the incident? (Table VI)Fifty percent of the incidents had no direct patient effect

(41% had no adverse event and 9% were a near miss). Tem-porary morbidity occurred in 29%, permanent morbidity in14%, and death in 3% of the incidents.

6. Did the incident result in litigation? (Table VII)Respondents noted litigation in only 4% of the incidents.Data overview suggested another category of mapping,

as incidents involving injury to health-care workers were re-ported in the survey.

7. To whom did the incident occur or who was theinjured person? (Table VIII)

Patients accounted for the largest portion (65%). A con-siderable segment of incidents (24%) were general in nature anddid not impact directly down to the patient level. For example, aprosthesis of an incorrect size that passed onto the field but was

TABLE VI What Was the Outcome of the Incident?

No adverse event 41%

Near miss 9%

Adverse event with short-term morbidity 29%

Adverse event with permanent morbidity 14%

Death 3%


TABLE VII Did the Incident Result in Litigation?

Yes 4%

No 57%

Undetermined or potentially 30%


TABLE V How Would You Classify This Event?*

Communications failure 24.7%

Equipment and/or instrumentation problem inoperating room

20.0%

Improper technique and/or physician impairment 12.7%

Patient injury event 10.6%

Equipment problem with implants 9.0%

Wrong-site surgery 8.2%

Medication error 8.2%

Transition-of-care problem 6.3%

Imaging studies problem 6.1%

Blood or tissue event 5.5%

Adverse drug reaction 5.3%

Patient identification problem 2.0%

Antibiotic prophylaxis event 1.6%

Other 17.8%

*Multiple responses were accepted.

TABLE VIII Incidents Noted for Person Injured or to Whom

Incident Occurred

Incident occurred to patient 65%

Incident occurred to staff 6%

General incident with no direct impact 24%

Unknown or unable to classify 5%

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discovered before implantation would be an error; however, itwould be considered as general in nature and not impactingdown to the patient or person level. Incidents that directlyinvolved medical providers (e.g., needle sticks) accounted for 6%.

Comparison of Ear, Nose, and Throat Surgery andOrthopaedic Data (Table I)Table I shows the frequency data for ear, nose, and throatsurgery and for orthopaedics for all sixteen categories in theear, nose, and throat surgery classification system12. In the ear,nose, and throat surgery survey12, the medical errors that oc-curred with the highest frequency were technical incidents(19.3%) followed by medication (13.7%) and testing (10.4%)incidents. Wrong-site surgery represented 6.1% of the reports.In orthopaedics, the top two categories (equipment at 29%and communication at 24.7%) made up more than half of theincidents (53.7%). Medication errors accounted for 9.7% andwrong-site surgery for 5.6%.

JCAHO-NQF Taxonomy (Fig. 1, Table IX)This classification works like a branching decision tree witheach upper level box potentially dividing into several boxes onthe next lower level (Fig. 1). The primary node (an upper levelbox) for ‘‘impact’’ reflects the degree of harm to the patient9,10.For the next level subclassification of impact, orthopaedic nar-ratives rarely mentioned psychological issues (0.2%) and weredirected mostly to the physical aspects (83.6%). This area ofclassification has the potential for underreporting, particularlyon the psychological side.

Further dividing the physical subcategory into nine ad-ditional subcategories in the next level down shows the mostfrequent subclassification was ‘‘no detectable harm’’ (23.8%),followed by ‘‘moderate-temporary harm’’ (18.2%) and ‘‘severe-temporary harm’’ (11.6%). The worst subcategory of ‘‘physical’’impact was ‘‘death’’ (2.1%).

In the secondary subclassification of the primary node(upper box) ‘‘setting,’’ the operating room had the overall highestfrequency of error (54.2%). Subacute care settings were thenext most frequent location (13.5%). The emergency roomhad 6% of the errors, and interventional radiology had 2.5%.

NCC MERP Classification of Medication Errors (Table X)A detailed breakdown of medication errors into nine classes isoutlined in Table X. In addition, there are four subclassifica-tions according to the potential or actual harm level of theerror. The least serious category, in which no error occurred atthe patient level but events had a capacity for error, comprised4.3%. An example of this category would be the ordering ofan antibiotic to which the patient was allergic (technically, amedical error), but the error was caught before the antibioticwas administered (no effect at the patient level, but the ca-pacity for harm existed). Errors at the patient level that in-volved no harm were 48.9%. Instances that reached the patientlevel and caused patient harm constituted 42.5%. The fourthand most serious category of error resulting in or contributingto a patient death was 4.3% (two patients).

Subanalysis of Equipment, Communication, MedicationErrors, and Wrong-Site SurgeryThe general classifications indicated that orthopaedic errorsoccurred with highest frequency in the categories of equip-ment (29%) and communication (24.7%). However, the most

TABLE IX JCAHO-NQF Taxonomy

Impact Resulting from Incident*

Percentage of TotalNo. of Incidents†

(N = 483)

1.01 Medical 0.21.01.01 Psychological 0.1

1.01.01.01 No harm 0.01.01.01.02 No detectable harm 0.01.01.01.03 Mild-temporary harm 0.01.01.01.04 Mild-permanent harm 0.01.01.01.05 Moderate-temporary harm 0.01.01.01.06 Moderate-permanent harm 0.01.01.01.07 Severe-temporary harm 0.01.01.01.08 Severe-permanent harm 0.01.01.01.09 Profound mental harm 0.1

1.01.02 Physical 83.61.01.02.01 No harm 11.41.01.02.02 No detectable harm 23.81.01.02.03 Minimal-temporary harm 4.61.01.02.04 Minimal-permanent harm 0.61.01.02.05 Moderate-temporary harm 18.21.01.02.06 Moderate-permanent harm 7.21.01.02.07 Severe-temporary harm 11.61.01.02.08 Severe-permanent harm 4.11.01.02.09 Death 2.1

1.02 Nonmedical1.02.01 Patient/family satisfaction:premitigation and postmitigation

NA

1.02.01.01 Extremely dissatisfied NA1.02.01.02 Dissatisfied NA1.02.01.03 Neutral NA1.02.01.04 Satisfied NA1.02.01.05 Extremely satisfied NA

1.02.02 Legal 2.01.02.03 Social NA1.02.04 Economic NA

Unknown 16.1

*Primary node impact (1) with secondary subclassification tomedical (1.01) and nonmedical (1.02), followed by tertiary sub-classification, e.g., psychological (1.01.01), and quaternary sub-classification into degree of harm, e.g., no harm (1.01.01.01).Orthopaedic errors appear principally to impact on the patientphysically (1.01.02), comprising 83.6% of errors. The most fre-quent physical subclassification was ‘‘no detectable harm’’(23.8%), followed by ‘‘moderate-temporary harm’’ (18.2%) and‘‘severe-temporary harm’’ (11.6%). The two worst categories ofinjury and their relative incidence were severe-permanent harm(4.1%) and death (2.1%). †NA = not applicable.

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life-threatening errors involved drug adverse events. Thus,further subanalysis was thought to be warranted in these threeareas (equipment, communication, and medications). Wrong-site surgery has been a special interest area of the AAOS formany years and also underwent subanalysis.

Equipment Errors SubanalysisEquipment errors (29% of all reported incidents) were initiallybroken down into three primary subcategories. Instrumenta-tion problems (63.2%) occurred approximately twice as fre-quently as implant errors (31.6%). A further division of thetwo high-frequency categories (instrumentation errors andimplant errors) was performed.

In the secondary subanalysis of instrumentation errors,technical use errors (29.6%) occurred most often. Examplesinclude excessive tibial resection secondary to an improperlyassembled cutting jig. Missing parts (28.6%) was almost asfrequent. On the next tier of frequency were sterility problems(16.4%) and intraoperative breakage (14.3%).

Regarding the impact to the patient by equipment errors,surgery was cancelled in 11.6% of the cases, the surgical planwas altered in 16.8%, surgery was prolonged in 12.3%, andreoperation was necessary in 8.4% of the cases. An extended‘‘orthopaedic time out’’ (checking allergies, antibiotics, rec-ords, imaging, and equipment) was estimated to have beenpotentially able to detect a problem and prevent a medicalerror in approximately 16.8% of these cases.

Implant Errors SubanalysisThe implant-related error with the highest rate was missingimplants (42.9%). Having the wrong implant constituted28.6% of the incidents. Less common problems were late ar-rival (12.2%), an implant that broke intraoperatively (6.1%),and the implant that broke preoperatively (2.0%).

Communication Errors SubanalysisThe initial breakdown of communication errors was into fivecategories by the format of the communication. Incidents couldtally to more than one category. There were compounding er-rors in some incidents. The incidents involved verbal (16.0%),written (29.1%), and dictated comments (0.7%). Errors in-volved protocols already in place in 31.2% of the cases, andfailure to communicate constituted 23.4% of the cases.

The venue of communication errors was the hospital(81.9%), rehabilitation unit or nursing home (4.7%), surgerycenter (1.6%), and office or clinic (11.8%). The hospital venuewas further subdivided into the operating room, including thepreoperative holding area (35.5%); the postanesthesia care unit(2.9%); the intensive care unit (1%); the surgical floor (30.7%);the radiology department (9.6%); and the laboratory (5.8%).

The medical personnel involved in communication er-rors were tallied. More than one provider could be involved perincident. The orthopaedic surgeon was involved in 24.3% ofthe incidents and other physicians, in 16.5%. Nurses in theoperating room (not during an actual case) were involved in7.1% and circulators, scrub nurses, and/or technicians (during

a case), in 15.7%. Floor nurses were associated with 16.4% ofthe incidents; physician assistants, with 1.4%; office staff, with10%; and pharmacists, with 3.6%. Industry representativeswere involved with 5% of the communication errors.

At the patient level, communication errors resulted in anear miss in 19.4% of the incidents. Errors reaching the patient

TABLE X Breakdown of Forty-seven Medication Errors by the

NCC MERP Classification System*

NCC MERPClass Description

No. (%)of Cases

HarmLevel†

A Circumstances or eventsthat have the capacity tocause error

2 (4) 0

B An error occurred but theerror did not reach thepatient (An ‘‘error ofomission’’ does reachthe patient)

1 (2) *

C An error occurred thatreached the patient but didnot cause the patient harm

9 (19) *

D An error occurred thatreached the patient andrequired monitoring toconfirm that it resulted in noharm to the patient and/orrequired intervention topreclude harm

13 (28) *

E An error occurred that mayhave contributed to orresulted in temporary harmto the patient and requiredintervention

5 (11) 1

F An error occurred that mayhave contributed to orresulted in temporary harmto the patient and requiredinitial or prolongedhospitalization

9 (19) 1

G An error occurred that mayhave contributed to orresulted in permanentpatient harm

2 (4) 1

H An error occurred thatrequired interventionnecessary to sustain life

4 (9) 1

I An error occurred that mayhave contributed to orresulted in thepatient’sdeath

2 (4) #

*Nine classes (A through I), ranking from the least potential forpatient harm (A) to an error contributing to a patient death (I). †Theharm level is broken down into four additional subcategories: 0 =

categories where no error occurred but events had a capacity forerror, * = error but no harm, 1 = error with harm to patient, and # =

error resulting in patient death.

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level but resulting in no harm were involved in 47.6% of theincidents. An error reached the patient level and caused anegative outcome in 33% of the incidents. The negative impactto patients varied from minor delays of surgery to revision kneearthroplasty (when a wrong-sided prosthesis was implanted).

Serious Medication Incidents Subanalysis (Table X)The last three categories (G, H, and I) of the NCC MERPclassification15 of medication errors involve instances of per-manent harm or death. In the AAOS study, eight patients(17%) fell into these categories (two died, four required in-tervention to sustain life, and two sustained permanent harm).Both deaths occurred on the hospital ward and involved nar-cotic medications. Two of the patients in the H and I categorieswere in the operating room. One sustained a cardiac arrestafter a high spinal anesthetic, and the other patient sustained acardiac arrest at the end of a procedure after receiving a finaldose of a supposedly epidural anesthetic and the nurse anes-thetist had turned off the pulse oximeter alarms.

Wrong-Site Surgery SubanalysisThere were twenty-seven incidents of wrong-site surgery. Fiveof these did not include sufficient detail for type subanalysis.The remaining twenty-two were broken down by type ofwrong-site surgery. The majority (59%) involved the wrongside. However, there were also five instances (23%) of otherwrong location (e.g., the wrong finger on the correct hand),three wrong procedures (14%), and one wrong patient (5%).

In terms of anatomic location, seven of the twenty-seven didnot have specific anatomic descriptions. The remaining twentyincidents were classified by anatomic site. The knee and the fingersand/or hand both accounted for the highest number of occur-rences (35% each). The next most frequent anatomic location wasthe foot and ankle (15%). There were two incidents of a tractionpin being placed in the distal end of the femur on the wrong side(10%) and one instance of spine surgery at the wrong level (5%).

Discussion

Population surveys have limitations. In this survey, re-sponses were received from a relatively low percentage of

the target population. In addition, there is a potential for recallbias with an event time frame of several months. These factorslimit confidence in the generalizability of population surveyresults. Thus, we believe that the appropriate level of utility forthis study is for trending purposes to help to focus qualityassurance efforts and as a motivator for more detailed research.

In this survey of orthopaedic surgeons, the category ofequipment-related errors had the highest rate of incidents(29%), perhaps not surprising given our technology-intensiveprocedures. Communication errors had the second highestrate (24.7%). These two categories constituted 53.7% of thetotal number of errors. This contrasts with a broader distri-bution from the ear, nose, and throat surgery survey12, in whichfour categories made up 53.3% of the errors (technical errorsat surgery comprised 19.3% of the errors; medication, 13.7%;testing, 10.4%; and surgical planning, 9.9%).

The impact of equipment-related errors on patients wascommon, with effects reaching the patient level in 49.1% of theincidents. Fortunately, most consequences were minor, and only8.4% of the events required a reoperation. Communication er-rors were the second most frequent error (24.7%). A subanalysisshowed the largest proportion (31.2%) occurred when there wasa ‘‘protocol in place,’’ such as radiographs not arriving for ascheduled surgical case. The second largest category was ‘‘failureto communicate’’ (23.4%). Some of these occurrences might beaddressed by strategies outside normal quality assurance pro-grams. Failure to notify the surgeon that a wrong-sided kneeprosthesis passed onto the operating field may result from ahierarchical, sometimes intimidating, environment. ‘‘Crew re-source management’’ as developed in the aviation field17 couldhave application to this medical situation18.

Verbal communication errors constituted 16% of theincidents. The JCAHO 2008 National Patient Safety Goalsspecify clear read-back on verbal orders19. Errors resulting fromwritten communication were involved in 29.1% of the inci-dents. Creating an organizational culture with accurate com-munication (particularly with medication administration) hasbeen identified as an area requiring nursing, hospital, and/orpharmacy initiatives20-22.

Orthopaedic surgeons were involved in communicationerrors 24.3% of the time. The AAOS has already embarkedon a communication skills mentoring program in conjunctionwith the Institute for Healthcare Communication (previouslythe Bayer Institute for Healthcare Communication)23,24.

It is disconcerting that wrong-site surgeries continue tooccur. The orthopaedic survey was sent out two months afterthe JCAHO Universal Protocol for Preventing Wrong Site,Wrong Procedure, Wrong Person Surgery25-27 became manda-tory. JCAHO statistics corroborated an ongoing incidence ofwrong-site surgery 28,29. These data led the JCAHO to conveneanother Wrong Site Surgery Summit29 on February 23, 2007.The surgery team’s full and precise compliance with the Uni-versal Protocol was identified as the major issue surroundingthe persistent occurrence of wrong site surgery29. Subanalysisfound that the leading factor contributing to these incidentswas communication problems (>60%)30.

The types and locations of wrong-site surgery in ortho-paedics mirror those in the JCAHO analysis for events in the 2006calendar year29. The errors involved the wrong side in 59.1% ofthe incidents in the present study and 56% in the JCAHO study;other wrong location, such as the wrong digit on the correcthand, in 22.7% and 19%, respectively; the wrong procedure, in13.6% and 8%; and the wrong patient in 4.5% and 17%. Thereis clearly a need for a diverse, systems approach to preventmedical errors. One barrier, such as the institution of a ‘‘timeout’’ in the operating room, is inadequate. Multiple preventativesystems barriers are needed to avoid diverse types of error.

Medication errors are also an ongoing source of concernfor orthopaedics31 and medicine in general. Medication errorsrepresented 9.7% of the orthopaedic error reports. In this sur-vey, both patient deaths attributable directly to an error resultedfrom medication errors involving narcotic administration on

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the hospital ward. A JCAHO 2008 National Patient Safety Goalis to ‘‘improve the safety of using medications.’’19 The NCCMERP also has a focus on medication errors15. Computerizedorder-entry systems have been explored as a possible strategy forerror prevention32, and the AAOS has an Information Statementon Prevention of Medication Errors31.

Communicating medical errors to patients and family iscontroversial. The AAOS published an advisory statement in2004 indicating that adverse events should be disclosed ‘‘directlywith a patient/family member in an honest, compassionatemanner as soon as possible after an adverse event occurs.’’33 Anarticle in the American Medical News reported that several states(California, Georgia, Massachusetts, Texas, and Vermont) havepassed legislation ‘‘protecting statements or other benevolentgestures expressing sympathy from being admitted as evidenceof liability in medical malpractice and other accident cases.’’34

In Colorado, the Colorado Physicians Insurance Corpo-ration (COPIC), the physician-owned professional liability car-rier, has developed a novel program for dealing with adverseevents and medical errors35,36. Both the present COPIC ChiefExecutive Officer, Ted Clarke, MD, and his predecessor, K.Mason Howard, MD, are orthopaedic surgeons. Dr. Howardalso coauthored one of the two articles37,38 that formed the basisof the Institute of Medicine report To Err Is Human: Buildinga Safer Health System6. The COPIC 3R’s Program (Recognize,Respond, Resolve) provides for ‘‘open and honest communica-tion with the patient,’’35 includes physician training for disclosingunanticipated outcomes, and provides no-fault compensa-tion for a patient’s out-of-pocket expenses (a limit of $30,000).Patients are not required to sign documents stipulating thatthey will not file a lawsuit. A summary of this program waspublished in the New England Journal of Medicine36. Followingimplementation, the number of expected lawsuits resultingfrom adverse events was reduced35,36.

Physician attitudes and experience toward disclosingerrors to patients have been surveyed39. Patients are not oftentold of medical errors, particularly those that do not result inharm. The largest barrier identified by physicians in both theUnited States and Canada was the malpractice environment.

Dr. John Eisenberg, the late Director of the Agency forHealthcare Research and Quality (AHRQ), was a strong ad-vocate for changing the present culture of ‘‘finger pointing’’(the name, blame, and shame approach) and moving toward asystems-oriented methodology for addressing medical errors40.He believed that continuing education was the key to culturemodification. Resistance to the adoption of patient safetypractices continues, however, even in circumstances in whichthere is good evidence of effectiveness41.

In conclusion, medical errors continue to be a cause ofconcern. To our knowledge, the AAO-HNS and the AAOS arethe only two specialty medical societies to conduct patientsafety surveys. The AAOS member survey has allowed anoverview of the occurrence of errors within orthopaedics.Equipment errors and communication errors appear to bethe most frequently observed types, and medication errors hadthe most serious consequences for patients. Trends identified

in the analysis of error categories can serve as a guide to qualityassurance efforts.

The elimination of wrong-site surgery has been a priorityof the AAOS and subspecialty societies for more than a decadewith the AAOS Sign Your Site initiative1 and, more recently, theNorth American Spine Society ‘‘Sign, Mark and X-Ray’’ pro-gram42. The JCAHO has mandated the Universal Protocol25,26,which includes the three elements of patient identification,surgical site marking, and calling ‘‘time out’’ prior to incision.The latest Wrong Site Surgery Summit, convened by theJCAHO in February 2007, concluded that the Universal Pro-tocol was a well-constructed policy29. However, efforts neededto be redoubled to educate physicians, hospitals, and otherhealth-care institutions regarding the underlying principles ofthe protocol. In addition, specific attention needed to be paidto the details of the protocol by all individuals on the surgicalteam or wrong-site surgeries would continue to occur.

Leadership has been identified as a key factor in creatinga culture of safety in medical practice43. In orthopaedics, pa-tient safety continues to be a high priority for the AAOS andmembers of the AAOS Board of Specialty Societies, such as theNorth American Spine Society. The American volume of TheJournal of Bone and Joint Surgery, as the premier respectedjournal in the orthopaedic specialty, has highlighted the impor-tance of patient safety in its editorial pages44 and OrthopaedicForum section3,5, as well as with the publication of peer-reviewedpapers45-47.

Data from the AAOS Patient Safety Survey will enhancethe ability of orthopaedic surgeons to safely look after patients.Further, the results of the survey serve as an indicator for qualityassurance efforts, point to areas of potential additional research,and help to maintain the leadership role of orthopaedic surgeryin creating a ‘‘culture of safety’’ in medicine. n

NOTE: The authors thank Sylvia Watkins-Castillo and her staff at the AAOS Department of Re-search for their assistance in disseminating the survey and collating the responses. They alsothank Katherine Wong from Denver Spine for organizing the equipment and communicationsubanalysis.

David A. Wong, MD, MSc, FRCS(C)Denver Spine, Suite 100, 7800 East Orchard Road,Greenwood Village, CO 80111. E-mail address: [email protected]

James H. Herndon, MDMassachusetts General Hospital, 55 Fruit Street,White #542, Boston, MA 02114

S. Terry Canale, MDCampbell Foundation, 1211 Union Avenue,Suite 510, Memphis, TN 38104

Robert L. Brooks, MD, PhD, MBADelmarva Foundation for Medical Care, 6940Columbia Gateway Drive, Columbia, MD 21046-2788

Thomas R. Hunt, MDUniversity of Alabama, FOT 930, 510 20th Street South,Birmingham, AL 35294

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Howard R. Epps, MDFondren Orthopedic Group, 7401 South Main Street,Houston, TX 77030

Steven S. Fountain, MDNorthern California Mutual, P.O. Box 5940,La Quinta, CA 92248

Stephen A. Albanese, MDUniversity of Upstate New York, 550 Harrison Street,Suite 128, Syracuse, NY 13202

Norman A. Johanson, MDDrexel University College of Medicine, 245 North 15th Street,Room 7209, Philadelphia, PA 19096

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