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Medical Errors in Orthopaedics: Results of an AAOS Member Survey

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

Journal of Bone & Joint Surgery - American Volume: 01 March 2009 - Volume 91 - Issue 3 - p 547–557
doi: 10.2106/JBJS.G.01439
Scientific Articles

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).

1Denver Spine, Suite 100, 7800 East Orchard Road, Greenwood Village, CO 80111. E-mail address: ddaw@denverspine.com

2Massachusetts General Hospital, 55 Fruit Street, White #542, Boston, MA 02114

3Campbell Foundation, 1211 Union Avenue, Suite 510, Memphis, TN 38104

4Delmarva Foundation for Medical Care, 6940 Columbia Gateway Drive, Columbia, MD 21046-2788

5University of Alabama, FOT 930, 510 20th Street South, Birmingham, AL 35294

6Fondren Orthopedic Group, 7401 South Main Street, Houston, TX 77030

7Northern California Mutual, P.O. Box 5940, La Quinta, CA 92248

8University of Upstate New York, 550 Harrison Street, Suite 128, Syracuse, NY 13202

9Drexel University College of Medicine, 245 North 15th Street, Room 7209, Philadelphia, PA 19096

Copyright 2009 by The Journal of Bone and Joint Surgery, Incorporated
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