Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Brent Graham, MD, FRCSC*,
University of Toronto, Toronto, Canada
Posted March 2009
The article by Wong et al. focuses on the important and topical issue of medical
error in orthopaedic surgery. There are a few important general conclusions that
may be made on the basis of their findings, the most fundamental of which is
that errors clearly do occur in orthopaedic surgery and can affect a substantial
number of our patients. However, it is debatable whether the figures reported
by the authors have any meaning other than at the most qualitative level because
the study contains important methodological shortcomings, the most notable of
which is the small response rate to their survey (less than 17%) and the unclear
distinction that they make between a complication and an error. The authors tried
to adapt an instrument that was initially developed for the study of medical
error in ear, nose, and throat surgery1, but it isn't clear whether
this instrument could be expected to effectively measure the occurrence of similar
errors in orthopaedic surgery.
All survey research is affected by bias in the response group, and this bias
may be particularly problematic when the overall response rate is especially
low. Respondents to a survey almost always have a reason for participating. Whether
this reason is an interest in the topic or the desire to vent a personal grievance,
the impact on the observations usually cannot be quantified.
A major limitation of the study is that, while the authors have shown that
medical error may or may not lead to an occurrence of what would be considered
as a complication of treatment, they cannot account for complications that take
place without recognition of any specific, well-defined error. Of course, some
complications, perhaps even a majority, may not be explainable, but the important
point is that appropriate operational definitions for medical error and for the
quite separate occurrence of a complication of treatment, whether or not it is
related to an error, should be established. This extends perhaps even more particularly
to issues of diagnostic accuracy and to the selection of treatment. As the authors
state in their description of the system of classification that was developed
by Shah et al.2: "Errors were broken into broad categories such as
errors in diagnosis, medical management…" This implies that the correct
evidence-based diagnosis or management can always be known. Clearly this isn't
the case in orthopaedic surgery or in most branches of clinical medicine. It
isn't likely that the authors meant to imply that these standards exist, but
their statement underlines the importance of having unequivocal, clear, and meaningful
definitions for medical errors, based on a consensus of clinicians. The authors' definition
that "Anything that has happened anywhere in your practice…that was not anticipated,
should not have happened, and makes you say 'I don't want this to happen again'"
is simply too vague to be useful.
The use of the general error classification system that was developed by Shah
et al. is a reasonable starting point, but what remains unclear is how accurately
this system can measure the phenomenon of medical error in orthopaedic surgery.
As in so many other areas of orthopaedic practice, what is required is the same
methodologically rigorous approach to the study of medical error as is now expected
in any other area of clinical research. The study by Wong et al. should be seen
as a preliminary finding that medical error exists in orthopaedic practice. Orthopaedic
surgeons should, through their professional organizations, be proactive in establishing
consensus on what constitutes a medical error and in devising methods of measurement
that will be meaningful to both the patient and the clinician in measuring the
effects of these errors. Until this kind of scientific approach is taken, the
magnitude, causes, and significance of medical error in orthopaedic surgery will
only be imperfectly understood.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
1. Dovey SM, Meyers DS, Phillips RL Jr, Green LA, Fryer GE, Galliher JM, Kappus J, Grob P. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002;11:233-8.
2. Shah RK, Kentala E, Healy GB, Roberson DW. Classification and consequences of errors in otolaryngology. Laryngoscope. 2004;114:1322-35.
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