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Medical Errors in Orthopaedics. Results of an AAOS Member Survey
David A. Wong, James H. Herndon, S. Terry Canale, Robert L. Brooks, Thomas R. Hunt, Howard R. Epps,
Steven S. Fountain, Stephen A. Albanese and Norman A. Johanson
J Bone Joint Surg Am. 2009;91:547-557. doi:10.2106/JBJS.G.01439
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The Journal of Bone and Joint Surgery
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547
C OPYRIGHT Ó 2009
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Medical Errors in Orthopaedics
Results 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 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).
T
Do medical errors in orthopaedics map to recognized
error classification systems?
Can trends that might assist in focusing orthopaedic
quality assurance efforts be identified?
Will a member survey show occurrence of medical
errors in orthopaedic practice?
Do wrong-site surgeries continue to occur despite the
AAOS Sign Your Site program and the Joint Commission on
the Accreditation of Healthcare Organizations (JCAHO) Universal Protocol?
The AAOS has been a recognized leader among professional
medical societies in proactively confronting issues of medical errors and patient safety 1-3. The first major safety initiative undertaken addressed wrong-site surgery. The AAOS Wrong Site
Surgery Task Force published its revised report in 19984. The
resulting voluntary program was christened the ‘‘Sign Your
Site’’ or ‘‘SYS’’ initiative. As a voluntary program, Sign Your
Site was not fully embraced by the Academy fellowship5.
The 2000 publication of the Institute of Medicine report
entitled To Err Is Human: Building a Safer Health System6 represents the seminal event stimulating widespread interest in
he Patient Safety Committee of the American Academy of
Orthopaedic Surgeons (AAOS) has recently completed
an analysis of a membership survey regarding medical errors in orthopaedic practice. The results were sought primarily
to assist ongoing, day-to-day efforts of the AAOS fellowship to
keep patients safe. An additional benefit was to help the Patient
Safety Committee and the Academy leadership to identify and
prioritize patient safety issues.
The research questions framed for the survey were:
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).
J Bone Joint Surg Am. 2009;91:547-57
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doi:10.2106/JBJS.G.01439
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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).
medical errors in the eyes of the public, news media, politicians,
and the medical profession. The Institute of Medicine’s conclusion that between 44,000 and 98,000 patient deaths per year
resulted from medical errors in hospitals in the United States
was widely publicized. As a result, patient safety has become a
noteworthy issue in many quarters.
To date, meaningful data on medical errors have come
from regulatory agencies and another surgical subspecialty society. The regulatory agency with the most experience analyzing
medical errors is probably the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). At the time
of publication of To Err Is Human, the JCAHO was already
looking at some specific errors (i.e., medication errors and
wrong-site surgery) by means of its Sentinel Events program7,8.
Other sentinel events (e.g., patient death) may have errors
identified during the ‘‘Root Cause Analysis’’ required for every
sentinel event. In addition to tabulating the incidence of sentinel events, the JCAHO developed a Patient Safety Event
Taxonomy for additional subanalysis of medical errors9. This
taxonomy system has been adopted by the National Quality
Forum (NQF)10. The NQF is a public-private partnered, notfor-profit organization ‘‘created to develop and implement a
national strategy for health care quality measurement and re-
porting.’’11 The JCAHO-NQF taxonomy (Fig. 1) thus has wide
acceptance and potential application.
The other professional medical society to publish a patient
safety membership survey involves ear, nose, and throat surgery 12
under the auspices of the American Academy of OtolaryngologyHead and Neck Surgery (AAO-HNS). A general classification
system of medical errors was developed by those authors after
review of the otolaryngology data (Table I). The ear, nose, and
throat surgery classification was used for broad analysis of the
orthopaedic survey. This allows some general comparisons of
errors between physician subspecialty surgical groups.
Drug-related errors have been a particular interest area in the
popular press13 and a focus of quality assurance efforts in hospitals14. The National Coordinating Council for Medication Error
Reporting and Prevention (NCC MERP) has developed a classification system of medication errors on the basis of the degree of
seriousness and/or harm (the potential for fatal error)15. There are
nine 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 unconscious
trauma victim) to I (‘‘An error occurred that may have contributed
to or resulted in the patient’s death’’). Both direct patient deaths in
the AAOS survey were associated with medication errors. It was
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TABLE I The Ear, Nose, and Throat Surgery Classification
System Comprising Sixteen General Categories of
Medical Errors
Distribution of Errors*
Ear, Nose,
and Throat
Surgery (N = 212)
Orthopaedic
Surgery
(N = 483)
History and physical
1.4%
1.2%
Differential diagnosis
or final diagnosis
1.4%
3.3%
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%
19.3%
13.0%
Ear, Nose, and Throat
12
Surgery Classification
Testing
Technical
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.
therefore thought appropriate to break down the orthopaedic
medication errors with use of the NCC MERP system.
Materials and Methods
n orthopaedic medical errors survey was developed by the
AAOS Patient Safety Committee with the assistance of
the AAOS Department of Research and consultation from the
marketing research firm Axxiom Healthcare Alliance. The orthopaedic survey was based on the ear, nose, and throat surgery
instrument previously reported by Shah et al.12, with minor
specialty-specific modifications. The AAOS Department of Research engaged Axxiom Healthcare Alliance to assist in the
feasibility and pilot testing from which the orthopaedic surgeryadapted version of the survey was produced. This early critical
incident research confirmed the hypothesis or research question
that medical errors were occurring in orthopaedics, thus suggesting that a wider survey would be worthwhile and applicable
to orthopaedic clinical practice. Responses also indicated that
established classification systems, such as the ear, nose, and
throat surgery general classification12, the JCAHO-NQF root
cause taxonomy 9,10, and the NCC MERP medication error classification15, were likely appropriate for mapping the data.
The first phase pilot (twenty-four subjects) was administered by Axxiom staff (to reduce bias) by means of a telephone
interview. Subsequently, a focus group was convened at the 2004
A
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AAOS Annual Meeting for a face-to-face description of critical
incidents and question feedback (again administered by Axxiom staff).
The pilot group was initially chosen according to age and
practice status (resident, member from thirty-five to forty-nine
years old, member over fifty years old, or emeritus fellow). The
group included representation from different practice settings
(academic or private and urban or more rural), although this
criterion was not a specific factor for inclusion. Orthopaedic
nurses were also part of the critical incident pilot, but it was
ultimately decided to survey physicians only (similar to the ear,
nose, and throat study). The time frame for error was more openended in the pilot as we were primarily interested in the richness of
the responses and therefore the reliability of the scripted questions, which ultimately helped to refine the survey. The feedback
suggested that patient-safety questions were understandable and
answered reliably by all segments of the membership. Axxiom
thought that the thirty-five to forty-nine-year age group provided
more detailed responses in the open-ended description portion of
the 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 limited
available funding, and consideration of the fact that the survey
research questions were directed to the occurrence and/or classification level rather than to therapeutics or clinical intervention,
it was thought that we could distribute the survey according to the
standard mailing protocol in place at the AAOS Department of
Research without further division, and a formal statistical analysis
of internal consistency was not performed.
The survey used the same operational definition of medical
error as that in the ear, nose, and throat instrument12 per Dovey
et al.16. ‘‘Anything that has happened anywhere in your practice
(office, hospital, operating room, emergency room, etc.) that
was not anticipated, should not have happened, and makes you
say ‘I don’t want this to happen again’. It can be small or large,
administrative or clinical—anything that you feel could be
avoided in the future.’’
The definition was printed at the beginning of the survey.
The Dovey interpretation is recognized as a broad, very inclusionary characterization of medical error. The potential for
blurring the line between a complication and a medical error is
recognized. However, it was decided to use the same definition as
the ear, nose, and throat surgery survey for consistency. The time
frame for reporting of medical errors was also chosen to reflect
the ear, nose, and throat surgery instrument (six months).
On the orthopaedic survey instrument, the error definition
was followed by six inquiries if an error was reported. These are
specifically outlined in the Results section (questions 1 through
6). The response format for these questions was multiple choice
(some using ‘‘all that apply’’ so that responses could fall into
multiple categories) followed by a write-in space for ‘‘other.’’ The
multiple choice options and the responses for each question are
outlined in Tables II through VII.
The respondent was then asked to insert a narrative
description of the event in a blank space. No patient-specific
data were requested.
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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
In-office surgery
Other in-office incident
Hospital
Surgery
Patient room or nursing unit
Emergency room
Unknown
Ambulatory care
Other area
Laboratory
Rehabilitation
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8%
1%
7%
78%
54%
10%
6%
2%
2%
2%
1%
1%
Ambulatory care center
7%
Long-term-care facility
1%
Other facility
2%
Unknown or no response
4%
patient safety) reviewed the raw data and/or categorization and
confirmed the final classification. A modified Delphi consensus
methodology was used. Equipment and communications task
forces (four-person subcommittees of the Patient Safety Committee) similarly reviewed the data and confirmed the classifications in these subdivisions. Incidents could tally in several
subcategories, resulting in variable numerators and denominators. Reporting is thus primarily expressed with use of percentages (in similar fashion and allowing general comparison to
the ear, nose, and throat surgery survey).
Ear, Nose, and Throat Surgery General Error
Classification System
A 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 general
in scope. Errors were broken into broad categories such as errors
in diagnosis, medical management, equipment, and wrong-site
surgery.
JCAHO-NQF Error Classification System
This is a more detailed system developed from experience of
JCAHO9,10 in evaluating root cause analyses in the Sentinel Events
program. The system is multitiered (primary, secondary, tertiary,
and quaternary levels) and appears similar to a decision-tree algorithm (Fig. 1). Each error is initially mapped through five primary nodes (impact, type, domain, cause, and prevention or
mitigation). At each subsequent level, assigning the incident to a
category leads to further subclassification on the next level down.
TABLE IV Who Was Involved in This Incident?*
The survey was sent to a cohort from the AAOS mailing list
(5540 of the total membership of approximately 20,000) by the
AAOS Department of Research. The members surveyed were
identified by the Department of Research according to protocols
in place to distribute surveys evenly across the AAOS mailing
list (with a view to limit the burden of individual members to
respond to frequent requests). The survey was forwarded in
August 2005. Responses were accepted until the end of the year.
Responses included no patient-specific information. Information was collated by the AAOS Department of Research.
Data were mapped primarily by the three classification systems
previously specified (ear, nose, and throat surgery general
classification; JCAHO-NQF root cause taxonomy system; and
NCC MERP classification for drug errors). The responses
generally were classified directly, but the research department
staff identified some situations for which clinical input was
requested to confirm mapping to a classification category. For
example, in the NCC MERP analysis of drug errors, categorization was clear if a death had resulted, but, for some descriptions, the research staff wanted clinical input into whether an
error fell into the ‘‘no harm’’ or ‘‘temporary harm’’ categories. A
classification task force (the Director of the Department of
Research, the Chairman of the Patient Safety Committee, and
an AAOS past president with specific interest and expertise in
Myself
60%
Nursing staff
37%
Another orthopaedic surgeon
19%
Another physician (nonorthopaedic)
16%
Intern or resident
13%
Radiology
7%
Nurse practitioner or physician assistant
Laboratory technician
5%
2%
Pharmacy
2%
Therapist
Other support personnel
Surgical or operating-room technician
Manufacturer’s representative
Administration
Equipment manager and/or management
Anesthesiologist
Assistants (SA, CRNA, etc.)
Patient or patient family
Other caregiver
Miscellaneous
1%
23%
4%
3%
2%
2%
1%
1%
1%
1%
1%
*Multiple responses were accepted. SA = surgical assistant, and
CRNA = certified registered nurse anesthesiologist.
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TABLE V How Would You Classify This Event?*
Communications failure
24.7%
Equipment and/or instrumentation problem in
operating 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
Imaging studies problem
6.3%
6.1%
Blood or tissue event
5.5%
Adverse drug reaction
5.3%
Patient identification problem
2.0%
Antibiotic prophylaxis event
Other
1.6%
17.8%
*Multiple responses were accepted.
A number is assigned to the options in each layer of subclassification. Frequency data can be ascertained for each category
at the various levels of analysis. A period is placed between the
numbers assigned at each level of classification. A wrong-site
surgery occurring in the hospital operating room (classification 3.01.01.05) is categorized through the tier of options as
follows (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 the
more detailed analysis of root cause issues.
Role of Funding
There was no external funding for this study.
Results
f the 5540 surveys, 917 were returned (a response rate of
16.6%). The response rate in the ear, nose, and throat surgery survey12 (18.6%) was similar. Of the 917 orthopaedic surgeon
respondents, 483 (53%) had noted a medical error in the previous
six months.
There were six primary questions in the survey instrument 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 location
of a smaller number of incidents.
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3. Who was involved in this incident? (Select all that
apply) (Table IV)
Between the reporting orthopaedic surgeon (60%) and
other orthopaedic surgeons (19%), AAOS fellows were involved
in almost all of the reported incidents. Nursing staff (37%) were
the next most frequent, followed by nonorthopaedic physicians
(16%) and interns and residents (13%).
4. How would you classify this event? (Select all that
apply) (Table V)
Communication failure and equipment and/or instrument 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). Temporary morbidity occurred in 29%, permanent morbidity in
14%, 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 reported in the survey.
7. To whom did the incident occur or who was the
injured person? (Table VIII)
Patients accounted for the largest portion (65%). A considerable segment of incidents (24%) were general in nature and
did not impact directly down to the patient level. For example, a
prosthesis of an incorrect size that passed onto the field but was
TABLE VI What Was the Outcome of the Incident?
No adverse event
Near miss
41%
9%
Adverse event with short-term morbidity
29%
Adverse event with permanent morbidity
14%
Death
3%
Unknown or no response
4%
TABLE VII Did the Incident Result in Litigation?
Yes
4%
No
57%
Undetermined or potentially
30%
Unknown or no response
9%
TABLE VIII Incidents Noted for Person Injured or to Whom
Incident Occurred
Incident occurred to patient
Incident occurred to staff
General incident with no direct impact
Unknown or unable to classify
65%
6%
24%
5%
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discovered before implantation would be an error; however, it
would be considered as general in nature and not impacting
down to the patient or person level. Incidents that directly
involved medical providers (e.g., needle sticks) accounted for 6%.
Comparison of Ear, Nose, and Throat Surgery and
Orthopaedic Data (Table I)
Table I shows the frequency data for ear, nose, and throat
surgery and for orthopaedics for all sixteen categories in the
ear, nose, and throat surgery classification system12. In the ear,
nose, and throat surgery survey12, the medical errors that occurred 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 the
incidents (53.7%). Medication errors accounted for 9.7% and
wrong-site surgery for 5.6%.
JCAHO-NQF Taxonomy (Fig. 1, Table IX)
This classification works like a branching decision tree with
each upper level box potentially dividing into several boxes on
the next lower level (Fig. 1). The primary node (an upper level
box) for ‘‘impact’’ reflects the degree of harm to the patient9,10.
For the next level subclassification of impact, orthopaedic narratives rarely mentioned psychological issues (0.2%) and were
directed mostly to the physical aspects (83.6%). This area of
classification has the potential for underreporting, particularly
on the psychological side.
Further dividing the physical subcategory into nine additional subcategories in the next level down shows the most
frequent subclassification was ‘‘no detectable harm’’ (23.8%),
followed by ‘‘moderate-temporary harm’’ (18.2%) and ‘‘severetemporary 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 highest
frequency of error (54.2%). Subacute care settings were the
next most frequent location (13.5%). The emergency room
had 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 is
outlined in Table X. In addition, there are four subclassifications according to the potential or actual harm level of the
error. The least serious category, in which no error occurred at
the patient level but events had a capacity for error, comprised
4.3%. An example of this category would be the ordering of
an antibiotic to which the patient was allergic (technically, a
medical error), but the error was caught before the antibiotic
was administered (no effect at the patient level, but the capacity for harm existed). Errors at the patient level that involved no harm were 48.9%. Instances that reached the patient
level and caused patient harm constituted 42.5%. The fourth
and most serious category of error resulting in or contributing
to a patient death was 4.3% (two patients).
Subanalysis of Equipment, Communication, Medication
Errors, and Wrong-Site Surgery
The general classifications indicated that orthopaedic errors
occurred with highest frequency in the categories of equipment (29%) and communication (24.7%). However, the most
TABLE IX JCAHO-NQF Taxonomy
Impact Resulting from Incident*
Percentage of Total
No. of Incidents†
(N = 483)
1.01 Medical
1.01.01 Psychological
1.01.01.01 No harm
1.01.01.02 No detectable harm
1.01.01.03 Mild-temporary harm
1.01.01.04 Mild-permanent harm
1.01.01.05 Moderate-temporary harm
1.01.01.06 Moderate-permanent harm
1.01.01.07 Severe-temporary harm
1.01.01.08 Severe-permanent harm
1.01.01.09 Profound mental harm
0.2
0.1
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.1
1.01.02 Physical
1.01.02.01 No harm
1.01.02.02 No detectable harm
1.01.02.03 Minimal-temporary harm
1.01.02.04 Minimal-permanent harm
1.01.02.05 Moderate-temporary harm
1.01.02.06 Moderate-permanent harm
1.01.02.07 Severe-temporary harm
1.01.02.08 Severe-permanent harm
1.01.02.09 Death
83.6
11.4
23.8
4.6
0.6
18.2
7.2
11.6
4.1
2.1
1.02 Nonmedical
1.02.01 Patient/family satisfaction:
premitigation and postmitigation
1.02.01.01 Extremely dissatisfied
1.02.01.02 Dissatisfied
1.02.01.03 Neutral
1.02.01.04 Satisfied
1.02.01.05 Extremely satisfied
1.02.02 Legal
1.02.03 Social
1.02.04 Economic
Unknown
NA
NA
NA
NA
NA
NA
2.0
NA
NA
16.1
*Primary node impact (1) with secondary subclassification to
medical (1.01) and nonmedical (1.02), followed by tertiary subclassification, e.g., psychological (1.01.01), and quaternary subclassification into degree of harm, e.g., no harm (1.01.01.01).
Orthopaedic errors appear principally to impact on the patient
physically (1.01.02), comprising 83.6% of errors. The most frequent 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 of
injury 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 three
areas (equipment, communication, and medications). Wrongsite surgery has been a special interest area of the AAOS for
many years and also underwent subanalysis.
Equipment Errors Subanalysis
Equipment errors (29% of all reported incidents) were initially
broken down into three primary subcategories. Instrumentation problems (63.2%) occurred approximately twice as frequently as implant errors (31.6%). A further division of the
two high-frequency categories (instrumentation errors and
implant errors) was performed.
In the secondary subanalysis of instrumentation errors,
technical use errors (29.6%) occurred most often. Examples
include excessive tibial resection secondary to an improperly
assembled cutting jig. Missing parts (28.6%) was almost as
frequent. 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 plan
was altered in 16.8%, surgery was prolonged in 12.3%, and
reoperation was necessary in 8.4% of the cases. An extended
‘‘orthopaedic time out’’ (checking allergies, antibiotics, records, imaging, and equipment) was estimated to have been
potentially able to detect a problem and prevent a medical
error in approximately 16.8% of these cases.
Implant Errors Subanalysis
The implant-related error with the highest rate was missing
implants (42.9%). Having the wrong implant constituted
28.6% of the incidents. Less common problems were late arrival (12.2%), an implant that broke intraoperatively (6.1%),
and the implant that broke preoperatively (2.0%).
Communication Errors Subanalysis
The initial breakdown of communication errors was into five
categories by the format of the communication. Incidents could
tally to more than one category. There were compounding errors in some incidents. The incidents involved verbal (16.0%),
written (29.1%), and dictated comments (0.7%). Errors involved protocols already in place in 31.2% of the cases, and
failure 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%), surgery
center (1.6%), and office or clinic (11.8%). The hospital venue
was further subdivided into the operating room, including the
preoperative 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 errors were tallied. More than one provider could be involved per
incident. The orthopaedic surgeon was involved in 24.3% of
the incidents and other physicians, in 16.5%. Nurses in the
operating room (not during an actual case) were involved in
7.1% and circulators, scrub nurses, and/or technicians (during
TABLE X Breakdown of Forty-seven Medication Errors by the
NCC MERP Classification System*
NCC MERP
Class
Description
No. (%)
of Cases
Harm
Level†
A
Circumstances or events
that have the capacity to
cause error
2 (4)
0
B
An error occurred but the
error did not reach the
patient (An ‘‘error of
omission’’ does reach
the patient)
1 (2)
*
C
An error occurred that
reached the patient but did
not cause the patient harm
9 (19)
*
D
An error occurred that
reached the patient and
required monitoring to
confirm that it resulted in no
harm to the patient and/or
required intervention to
preclude harm
13 (28)
*
E
An error occurred that may
have contributed to or
resulted in temporary harm
to the patient and required
intervention
5 (11)
1
F
An error occurred that may
have contributed to or
resulted in temporary harm
to the patient and required
initial or prolonged
hospitalization
9 (19)
1
G
An error occurred that may
have contributed to or
resulted in permanent
patient harm
2 (4)
1
H
An error occurred that
required intervention
necessary to sustain life
4 (9)
1
I
An error occurred that may
have contributed to or
resulted in the patient’s death
2 (4)
#
*Nine classes (A through I), ranking from the least potential for
patient harm (A) to an error contributing to a patient death (I). †The
harm level is broken down into four additional subcategories: 0 =
categories where no error occurred but events had a capacity for
error, * = error but no harm, 1 = error with harm to patient, and # =
error resulting in patient death.
a case), in 15.7%. Floor nurses were associated with 16.4% of
the incidents; physician assistants, with 1.4%; office staff, with
10%; and pharmacists, with 3.6%. Industry representatives
were involved with 5% of the communication errors.
At the patient level, communication errors resulted in a
near miss in 19.4% of the incidents. Errors reaching the patient
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level but resulting in no harm were involved in 47.6% of the
incidents. An error reached the patient level and caused a
negative outcome in 33% of the incidents. The negative impact
to patients varied from minor delays of surgery to revision knee
arthroplasty (when a wrong-sided prosthesis was implanted).
Serious Medication Incidents Subanalysis (Table X)
The last three categories (G, H, and I) of the NCC MERP
classification15 of medication errors involve instances of permanent harm or death. In the AAOS study, eight patients
(17%) fell into these categories (two died, four required intervention to sustain life, and two sustained permanent harm).
Both deaths occurred on the hospital ward and involved narcotic medications. Two of the patients in the H and I categories
were in the operating room. One sustained a cardiac arrest
after a high spinal anesthetic, and the other patient sustained a
cardiac arrest at the end of a procedure after receiving a final
dose of a supposedly epidural anesthetic and the nurse anesthetist had turned off the pulse oximeter alarms.
Wrong-Site Surgery Subanalysis
There were twenty-seven incidents of wrong-site surgery. Five
of these did not include sufficient detail for type subanalysis.
The remaining twenty-two were broken down by type of
wrong-site surgery. The majority (59%) involved the wrong
side. However, there were also five instances (23%) of other
wrong 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 did
not have specific anatomic descriptions. The remaining twenty
incidents were classified by anatomic site. The knee and the fingers
and/or hand both accounted for the highest number of occurrences (35% each). The next most frequent anatomic location was
the foot and ankle (15%). There were two incidents of a traction
pin 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
opulation surveys have limitations. In this survey, responses were received from a relatively low percentage of
the target population. In addition, there is a potential for recall
bias with an event time frame of several months. These factors
limit confidence in the generalizability of population survey
results. Thus, we believe that the appropriate level of utility for
this study is for trending purposes to help to focus quality
assurance efforts and as a motivator for more detailed research.
In this survey of orthopaedic surgeons, the category of
equipment-related errors had the highest rate of incidents
(29%), perhaps not surprising given our technology-intensive
procedures. Communication errors had the second highest
rate (24.7%). These two categories constituted 53.7% of the
total number of errors. This contrasts with a broader distribution from the ear, nose, and throat surgery survey12, in which
four categories made up 53.3% of the errors (technical errors
at surgery comprised 19.3% of the errors; medication, 13.7%;
testing, 10.4%; and surgical planning, 9.9%).
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The impact of equipment-related errors on patients was
common, with effects reaching the patient level in 49.1% of the
incidents. Fortunately, most consequences were minor, and only
8.4% of the events required a reoperation. Communication errors were the second most frequent error (24.7%). A subanalysis
showed the largest proportion (31.2%) occurred when there was
a ‘‘protocol in place,’’ such as radiographs not arriving for a
scheduled surgical case. The second largest category was ‘‘failure
to communicate’’ (23.4%). Some of these occurrences might be
addressed by strategies outside normal quality assurance programs. Failure to notify the surgeon that a wrong-sided knee
prosthesis passed onto the operating field may result from a
hierarchical, sometimes intimidating, environment. ‘‘Crew resource management’’ as developed in the aviation field17 could
have application to this medical situation18.
Verbal communication errors constituted 16% of the
incidents. The JCAHO 2008 National Patient Safety Goals
specify clear read-back on verbal orders19. Errors resulting from
written communication were involved in 29.1% of the incidents. Creating an organizational culture with accurate communication (particularly with medication administration) has
been identified as an area requiring nursing, hospital, and/or
pharmacy initiatives20-22.
Orthopaedic surgeons were involved in communication
errors 24.3% of the time. The AAOS has already embarked
on a communication skills mentoring program in conjunction
with the Institute for Healthcare Communication (previously
the Bayer Institute for Healthcare Communication)23,24.
It is disconcerting that wrong-site surgeries continue to
occur. The orthopaedic survey was sent out two months after
the JCAHO Universal Protocol for Preventing Wrong Site,
Wrong Procedure, Wrong Person Surgery25-27 became mandatory. JCAHO statistics corroborated an ongoing incidence of
wrong-site surgery 28,29. These data led the JCAHO to convene
another Wrong Site Surgery Summit29 on February 23, 2007.
The surgery team’s full and precise compliance with the Universal Protocol was identified as the major issue surrounding
the persistent occurrence of wrong site surgery29. Subanalysis
found that the leading factor contributing to these incidents
was communication problems (>60%)30.
The types and locations of wrong-site surgery in orthopaedics mirror those in the JCAHO analysis for events in the 2006
calendar year29. The errors involved the wrong side in 59.1% of
the incidents in the present study and 56% in the JCAHO study;
other wrong location, such as the wrong digit on the correct
hand, in 22.7% and 19%, respectively; the wrong procedure, in
13.6% and 8%; and the wrong patient in 4.5% and 17%. There
is clearly a need for a diverse, systems approach to prevent
medical errors. One barrier, such as the institution of a ‘‘time
out’’ in the operating room, is inadequate. Multiple preventative
systems barriers are needed to avoid diverse types of error.
Medication errors are also an ongoing source of concern
for orthopaedics31 and medicine in general. Medication errors
represented 9.7% of the orthopaedic error reports. In this survey, both patient deaths attributable directly to an error resulted
from medication errors involving narcotic administration on
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the hospital ward. A JCAHO 2008 National Patient Safety Goal
is to ‘‘improve the safety of using medications.’’19 The NCC
MERP also has a focus on medication errors15. Computerized
order-entry systems have been explored as a possible strategy for
error prevention32, and the AAOS has an Information Statement
on Prevention of Medication Errors31.
Communicating medical errors to patients and family is
controversial. The AAOS published an advisory statement in
2004 indicating that adverse events should be disclosed ‘‘directly
with a patient/family member in an honest, compassionate
manner as soon as possible after an adverse event occurs.’’33 An
article in the American Medical News reported that several states
(California, Georgia, Massachusetts, Texas, and Vermont) have
passed legislation ‘‘protecting statements or other benevolent
gestures expressing sympathy from being admitted as evidence
of liability in medical malpractice and other accident cases.’’34
In Colorado, the Colorado Physicians Insurance Corporation (COPIC), the physician-owned professional liability carrier, has developed a novel program for dealing with adverse
events and medical errors35,36. Both the present COPIC Chief
Executive Officer, Ted Clarke, MD, and his predecessor, K.
Mason Howard, MD, are orthopaedic surgeons. Dr. Howard
also coauthored one of the two articles37,38 that formed the basis
of the Institute of Medicine report To Err Is Human: Building
a Safer Health System6. The COPIC 3R’s Program (Recognize,
Respond, Resolve) provides for ‘‘open and honest communication with the patient,’’35 includes physician training for disclosing
unanticipated outcomes, and provides no-fault compensation for a patient’s out-of-pocket expenses (a limit of $30,000).
Patients are not required to sign documents stipulating that
they will not file a lawsuit. A summary of this program was
published in the New England Journal of Medicine36. Following
implementation, the number of expected lawsuits resulting
from adverse events was reduced35,36.
Physician attitudes and experience toward disclosing
errors to patients have been surveyed39. Patients are not often
told of medical errors, particularly those that do not result in
harm. The largest barrier identified by physicians in both the
United States and Canada was the malpractice environment.
Dr. John Eisenberg, the late Director of the Agency for
Healthcare Research and Quality (AHRQ), was a strong advocate for changing the present culture of ‘‘finger pointing’’
(the name, blame, and shame approach) and moving toward a
systems-oriented methodology for addressing medical errors40.
He believed that continuing education was the key to culture
modification. Resistance to the adoption of patient safety
practices continues, however, even in circumstances in which
there is good evidence of effectiveness41.
In conclusion, medical errors continue to be a cause of
concern. To our knowledge, the AAO-HNS and the AAOS are
the only two specialty medical societies to conduct patient
safety surveys. The AAOS member survey has allowed an
overview of the occurrence of errors within orthopaedics.
Equipment errors and communication errors appear to be
the most frequently observed types, and medication errors had
the most serious consequences for patients. Trends identified
in the analysis of error categories can serve as a guide to quality
assurance efforts.
The elimination of wrong-site surgery has been a priority
of the AAOS and subspecialty societies for more than a decade
with the AAOS Sign Your Site initiative1 and, more recently, the
North American Spine Society ‘‘Sign, Mark and X-Ray’’ program42. 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 the
JCAHO in February 2007, concluded that the Universal Protocol was a well-constructed policy29. However, efforts needed
to be redoubled to educate physicians, hospitals, and other
health-care institutions regarding the underlying principles of
the protocol. In addition, specific attention needed to be paid
to the details of the protocol by all individuals on the surgical
team or wrong-site surgeries would continue to occur.
Leadership has been identified as a key factor in creating
a culture of safety in medical practice43. In orthopaedics, patient safety continues to be a high priority for the AAOS and
members of the AAOS Board of Specialty Societies, such as the
North American Spine Society. The American volume of The
Journal of Bone and Joint Surgery, as the premier respected
journal in the orthopaedic specialty, has highlighted the importance of patient safety in its editorial pages44 and Orthopaedic
Forum section3,5, as well as with the publication of peer-reviewed
papers45-47.
Data from the AAOS Patient Safety Survey will enhance
the ability of orthopaedic surgeons to safely look after patients.
Further, the results of the survey serve as an indicator for quality
assurance efforts, point to areas of potential additional research,
and help to maintain the leadership role of orthopaedic surgery
in creating a ‘‘culture of safety’’ in medicine. n
NOTE: The authors thank Sylvia Watkins-Castillo and her staff at the AAOS Department of Research for their assistance in disseminating the survey and collating the responses. They also
thank Katherine Wong from Denver Spine for organizing the equipment and communication
subanalysis.
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, MD
Massachusetts General Hospital, 55 Fruit Street,
White #542, Boston, MA 02114
S. Terry Canale, MD
Campbell Foundation, 1211 Union Avenue,
Suite 510, Memphis, TN 38104
Robert L. Brooks, MD, PhD, MBA
Delmarva Foundation for Medical Care, 6940
Columbia Gateway Drive, Columbia, MD 21046-2788
Thomas R. Hunt, MD
University of Alabama, FOT 930, 510 20th Street South,
Birmingham, AL 35294
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Howard R. Epps, MD
Fondren Orthopedic Group, 7401 South Main Street,
Houston, TX 77030
Stephen A. Albanese, MD
University of Upstate New York, 550 Harrison Street,
Suite 128, Syracuse, NY 13202
Steven S. Fountain, MD
Northern California Mutual, P.O. Box 5940,
La Quinta, CA 92248
Norman A. Johanson, MD
Drexel University College of Medicine, 245 North 15th Street,
Room 7209, Philadelphia, PA 19096
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