The Journal of Bone and Joint Surgery (American). 2009;91:547-557.
doi:10.2106/JBJS.G.01439
© 2009 The Journal of Bone and Joint Surgery, Inc.
This Article
Right arrow Full Text
Right arrow Full Text (PDF)
Right arrow [Supplementary Material]
Right arrow Letters to the Editor: Submit a response
Right arrow Letters to the Editor: View responses
Right arrow Alert me when this article is cited
Right arrow Alert me when Letters to the Editor are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow Rights and Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Wong, D. A.
Right arrow Articles by Johanson, N. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Wong, D. A.
Right arrow Articles by Johanson, N. A.
Related Collections
Right arrow Adult Trauma
Right arrow Basic Science
Right arrow Spine
Right arrow Adult Hip
Right arrow Adult Knee
Right arrow Foot/Ankle
Right arrow Shoulder
Right arrow Elbow
Right arrow Hand/Wrist
Right arrow Sports
Right arrow Pediatrics
Right arrow Oncology
Right arrow Rehabilitation
Right arrow Education and Training
Right arrow Pain Management
Right arrow Ethics
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Facebook   Add to Technorati   Add to Twitter  
What's this?

Medical Errors in Orthopaedics

Results of an AAOS Member Survey

David A. Wong, MD, MSc, FRCS(C)1, James H. Herndon, MD2, S. Terry Canale, MD3, Robert L. Brooks, MD, PhD, MBA4, Thomas R. Hunt, MD5, Howard R. Epps, MD6, Steven S. Fountain, MD7, Stephen A. Albanese, MD8 and Norman A. Johanson, MD9

1 Denver Spine, Suite 100, 7800 East Orchard Road, Greenwood Village, CO 80111. E-mail address: ddaw{at}denverspine.com
2 Massachusetts General Hospital, 55 Fruit Street, White #542, Boston, MA 02114
3 Campbell Foundation, 1211 Union Avenue, Suite 510, Memphis, TN 38104
4 Delmarva Foundation for Medical Care, 6940 Columbia Gateway Drive, Columbia, MD 21046-2788
5 University of Alabama, FOT 930, 510 20th Street South, Birmingham, AL 35294
6 Fondren Orthopedic Group, 7401 South Main Street, Houston, TX 77030
7 Northern California Mutual, P.O. Box 5940, La Quinta, CA 92248
8 University of Upstate New York, 550 Harrison Street, Suite 128, Syracuse, NY 13202
9 Drexel University College of Medicine, 245 North 15th Street, Room 7209, Philadelphia, PA 19096

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).

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).


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Facebook Facebook   Add to Technorati Technorati   Add to Twitter Twitter    What's this?


This article has been cited by other articles:


Home page
 JBJSHome page
D. A. Wong, B. Lewis, J. Herndon, C. Martin Jr., and R. Brooks
Patient Safety in North America: Beyond "Operate Through Your Initials" and "Sign Your Site"
J. Bone Joint Surg. Am., June 1, 2009; 91(6): 1534 - 1541.
[Full Text] [PDF]

Letters to the Editor:

Read all Letters to the Editor

Orthopaedics – Matching Precision with Safety
Sukhmeet S Panesar, et al.
JBJS Online, 28 Jul 2009 [Full text]