Top medical mistakes in orthopedics include equipment, communication errors

Of the wrong-site surgeries reported in an AAOS member survey, 5% involved the wrong patient.

Issue: May 2009

LAS VEGAS — A recent survey of American Academy of Orthopaedic Surgeons members revealed that 53% of respondents reported a medical error in the last 6 months.

“We need to keep in mind that about one out of four orthopedic surgeons will have a wrong-site surgery incident in their career,” David A. Wong, MD, said during his presentation at the American Academy of Orthopaedic Surgeons (AAOS) 76th Annual Meeting. “Patient safety is no accident. In terms of quality assurance, equipment, communication and wrong-site surgery have been identified [as areas for improvement]. The academy has a number of programs to look at this along with the Joint Commission on the Accreditation of Hospital Organization (JCAHO). All of it is going to be pulled together by the new initiative of the Patient Safety Committee, which is the Highly Reliable Operating Room.”

Mailed survey

Wong, who is a member of the Orthopedics Today Editorial Board, and his colleagues from the AAOS Patient Safety Committee, surveyed 5,540 academy members by mail to determine the occurrence of orthopedic medical errors and identify areas for quality assurance efforts. The survey had a 16.6% response rate.

Of the 917 surgeons who responded, 483 reported medical errors in the past 6 months. The most frequent errors included equipment (29%) communication (24.7%) and medication errors (9.7%) and wrong-site surgery (5.6%). The respondents also reported two deaths, both of which involved narcotics. The survey showed that most of the errors occurred in the hospital and took place in the surgery suite (54%).

Most of the equipment errors involved problems with instrumentation. These problems included instruments that were missing from sets, technical-use problems and broken instruments both preoperatively and intraoperatively, Wong said. Implant-related problems constituted a third of the equipment errors.

“Interestingly, time-outs caught a lot of the equipment problems,” he said.

Wrong-site surgery

Of the wrong-site surgeries reported, the investigators found that 59% involved the wrong side and 23% were categorized as other wrong-site, such as the wrong digit on the correct hand. Wrong procedures accounted for 14% of the wrong-site surgeries, and 5% of surgeries were performed in the wrong person.

“This compares to the JCAHO data where, interestingly, 12% of the wrong-site surgeries were the wrong person,” Wong said.

He also noted that most common locations for wrong site surgery were the knee and fingers and/or hand (both 35%).

Ty Henry Goletz, MD, a co-moderator of the session, noted that surgeons often overestimate their number of surgeries and asked if the respondents could have underestimated their complications.

“That is clearly one of the limitations of a population-based study is you cannot double check the data,” Wong said. He also said that surgeons must be cognizant of wrong-site surgery. “Some of the communications errors, the equipment problems I think that the likelihood of getting 100% removal of those types of errors is low, but wrong-site surgery is one of the things that not only the academy, but the federal government has identified as one of those never, never events,” he said.

For more information:

Ty Henry Goletz, MD, can be reached at 7940 Floyd Curl Drive, Suite 560, San Antonio, TX 78229; 210-692-7400; e-mail: thgmd@sbcglobal.net. He receives miscellaneous non-income support from DePuy and is part of the company’s speakers bureau.

David A. Wong, MD, can be reached at Denver Spine Center, 7800 E. Orchard Road, Suite 100, Greenwood Village, CO 80111; 303-783-1300; e-mail: ddaw@denverspine.com. He is a part of the speakers bureau for Cervitech, Stryker, Zimmer and Anulex. He is also a paid consultant/employee for Stryker, Zimmer and Anulex, and has received research support from Abbot, Arcus, Cervitech, Stryker and Zimmer.

Reference:

Wong DA, Herndon JH, Castillo-Watkins S, et al. Medical errors in orthopedics: Results of an AAOS member survey. Paper #84. Presented at the American Academy of Orthopaedic Surgeons 76th Annual Meeting. Feb. 25-27, 2009. Las Vegas.