Emergency surgeries, multiple surgeons or procedures: risk factors for errors

Thomas R. Hunt III, MD, responds to questions posed by Douglas W. Jackson, MD, about how errors occur and ways to decrease them.

Issue: November 2004

ByThomas R. Hunt III, MD

ByDouglas W. Jackson, MD

Douglas W. Jackson, MD: What are the common orthopedic errors documented in closed claim data?

Thomas R. Hunt III, MD [photo]
Thomas R. Hunt III, MD,
Head, Section of Hand Surgery
Department of Orthopaedic Surgery
The Cleveland Clinic Foundation

Thomas R. Hunt III, MD: Data from closed malpractice claims provide critical information regarding the most common medical errors that occur in the practice of orthopedic surgery and the circumstances surrounding them. Because this information represents only those cases leading to disability or litigation, it in no way documents the frequency of these occurrences in the specialty.

These claims site errors in five major categories: performance, prevention, diagnosis, medication usage and systems employment. In 90% of cases the surgeon is accused of a technical mistake. The second most common reason for a suit is “failure to take precautions” (46%). Errors in diagnosis include failure to use an indicated test (36%), an avoidable delay in obtaining a test (36%), and failure to act on a test (21%).

Mistakes in medication dosage are cited 67% of the time, while use of an inappropriate drug is mentioned in 33% of cases. Inadequate communication and patient monitoring are common systems errors reported in 20% of these closed claims.

Payments were awarded in 30% of all orthopedic malpractice cases based on this past data. Interestingly, cases related to wrong site surgery, though infrequent (1.8%), were paid 84% of the time.

Jackson: What were the wrong site surgery data prior to “sign your site” programs?

Hunt: Wrong site surgery cases have risen dramatically in the United States over the last eight years. It is estimated that the current cumulative probability of performing wrong site surgery over a 35-year surgical career is approximately 25%. The Joint Commission on Accreditation of Healthcare Organizations reported that 16 events occurred in 1998 compared with 58 in 2001. Approximately 40% of the 240 wrong site surgery cases reported as sentinel events in the United States between 1995 and 2003 involved an orthopedic procedure, presumably because we operate on extremities, often without external manifestations of disease or injury.

The Canadian Orthopaedic Association initiated a prevention program in 1994, which reduced the already declining rate of wrong site surgery in that country by more than 60% in six years. This dramatic reduction occurred despite most hospitals not having a specific policy designed to avoid this problem.

The AAOS developed its position statement and the “sign your site” initiative in 1997 based at least partly on an extensive review of the closed malpractice claim data from 1985 to 1995 referenced earlier. During this time 341 claims were made, 225 of which were related to orthopedics. Most wrong site orthopedic surgery cases involved the knee, then the ankle and foot, the hip, the leg, the hand, and lastly the wrist.

Risk factors included an emergency operation, multiple surgeons, multiple procedures performed on the same patient and time pressure. In 46% of cases, physician error alone was blamed. Blame was assigned to the hospital staff 41% of the time for prepping and draping the wrong side.

Patients provided incorrect information about the site of surgery in 8%, and there was a documentation error on the permit or the X-ray resulting in wrong site surgery in 5%. The procedure most associated with wrong site surgery was arthroscopy, and in the majority of cases the error was discovered at the time of surgery.

An on-site survey by the AAOS shortly after an extensive awareness campaign revealed that 78% of orthopedic surgeons were aware of the program and only 46% had changed their practice accordingly. However, the overwhelming majority or AAOS fellows felt that the sign your site process would diminish wrong site surgery.

In 2002 members of the American Society for Surgery of the Hand — composed of orthopedic, plastic and general surgeons — were polled and 67% responded. Twenty-one percent of hand surgeons reported performing at least one wrong site surgery and another 16% said they had prepared to operate on the wrong site but corrected the error prior to making an incision. The risk of performing wrong site surgery increased with physician age, time in practice and caseload. There was no significant difference between practice-type and specialty despite a much higher awareness of the sign your site program among orthopedists.

Jackson: What has been learned from error analysis?

Hunt: Errors may be broadly classified as either cognitive or latent. Cognitive errors include skill-based slips, rule and knowledge-based mistakes, and those mistakes stemming from extreme emotional or environmental conditions.

Latent errors are common and represent a much more serious threat to patient safety. They result from system failures typically due to poor design or inadequate maintenance. In most cases, the caregiver is “set-up” to fail. While the cause of an event may appear to be due solely to human error, the true underlying cause may be well beyond the control of that particular person.

In 1991, Reason outlined his multicausal theory of adverse events, visually depicted in his “Swiss Cheese Model.” He postulated that for an adverse event to occur there are typically multiple failures in the complex system that is modern medicine.

In To Err is Human. Building a Safer Health System, the following factors were cited as potentially interacting and contributing to a chain of events ultimately leading to a medical error: poor communication, large numbers of providers contributing to the care of each patient (handoffs), stress and fatigue, human factors design flaws, poor training, higher illness acuity, need for rapid decisions, less staff support, few redundancies to prevent error, and technology interaction.

Due to the complex interactions involved, medical errors are most effectively investigated and countered by utilizing root cause and systems analysis techniques in which individual blame is de-emphasized and systematic vulnerabilities are exposed. From these investigations it is clear that we must decrease reliance on memory, improve information access, standardize systems and thoroughly train users. Computerized medication ordering is a good example of error proofing using this approach.

Jackson: What are some of the barriers to improvement in our practice environment?

Hunt: There are five primary barriers to improvement in patient safety: poor outcomes analysis and data availability and utilization, a culture of blame, honesty issues, lack of communication and teamwork, and competing priorities ranging from time pressures to limited resources.

These barriers stem from the fundamental goals of medical education as well as the realities of modern day medical practice and society. As outlined by Leape, physicians are trained to perform faultlessly and to control all aspects of their patient’s care. This culture of infallibility and responsibility is highly desirable in the care of patient but unrealistic in the prevention of medical error.

Physicians have a difficult time confronting the errors and investigating them, feeling all the while that they are solely to blame, not realizing that the root cause may be well out of their control. They often fail to report these events, especially near misses, for fear of colleague scorn, professional censure and litigation. Even if they gain critical information from the event, the learning is not shared and takes place in a vacuum.

For more information:

Furey A, Stone C, Martin R. Preoperative signing of the incision site in orthopaedic surgery in Canada. J Bone Joint Surg. 2002;84A:1066-1068.

Kohn LT, Corrigan JM, Donaldson MS, for the Committee on Quality of Health Care in America, Institute of Medicine. To err is human: Building a safer health system. Washington, D.C: National Academy Press. 1999.

Krizek, TJ. Surgical error: Ethical use of adverse events. Arch Safety. 2000;135:1359-1366.

Leape LL. Error in medicine. JAMA. 1994;272:1851-1857.

McNeil BJ. Shattuck lecture: Hidden barriers to improvement in the quality of care. N Engl J Med. 2001;345:1612-1620.

Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg. 2003;85A:193-197.

Reason J. Human Error. Cambridge, Mass: Cambridge University Press. 1992.