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Orthopedic groups aim at reducing patient fear following surgical error study
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The American Academy of Orthopaedic Surgeons and the American Board of Orthopaedic Surgery are working to inform the public about the “very low” risk of errors during orthopedic surgery after a recent study found the specialty to have the second-highest rate of surgical errors.
The study, published in the Archives of Surgery, showed that 22.4% of the wrong-site procedures involved specialists in orthopedic surgery.
In the study, Colorado investigators analyzed a prospective physician insurance database — provided by a company that provides professional liability coverage to 6,000 practicing Colorado physicians — from January 1, 2002 to June 1, 2008. Of the 27,370 clinician-reported adverse events in the database during the study period, there were 25 wrong-patient and 107 wrong-site procedures.
Five of the wrong-patient procedures (20%) and 38 of the wrong-site procedures (35.5%) caused significant patient harm, including one patient who died after a wrong-site procedure.
Taken out of context
“While even one error is too many, we do not want the numbers cited in this study to be taken out of context and drive fear in any patient,” the Executive Director of the American Board of Orthopaedic Surgery (ABOS), Shepard Hurwitz, MD, stated in a press release.
Every year, the ABOS collects national data on each orthopedic surgeon who applies for certification and re-certification. As part of the requirement, these physicians submit case histories. The case histories are then used to extrapolate data.
“Over a period of 12 years, the ABOS has collected national data on more than 1 million orthopedic surgeries, and 71 of them included a wrong-site surgery,” Hurwitz stated in the release. “Any number more than one means a mistake occurred, however 71 out of 1 million is a very low percentage of incidence. Even so, we continue together to work toward improvement.”
Causes for error
In the Colorado study, diagnosis and communication errors were reported as the main causes leading to wrong-patient procedures. Eighty-five percent of wrong-site procedures were related to judgment errors, and 72% were related to “not performing a time-out.”
In addition, the authors found that nonsurgical disciplines were responsible for an equal number of patient injuries related to wrong-site procedures. Twenty-four percent of wrong-patient procedures were the responsibility of internal medicine specialists, with 8% each involving clinicians in family or general practice, pathology, urology, obstetrics-gynecology and pediatrics.
The Patient-Safety Committee of the American Academy of Orthopaedic Surgeons (AAOS) has instituted past campaigns and summits aimed at lowering the risks of surgical error in the operating room.
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“Human beings operate, therefore human error will never be eliminated,” Jeffrey Anglen, MD, an orthopedic surgeon and member of the AAOS Patient Safety Committee, stated in the release. “But, we believe wrong-site surgery stats can be reduced with scientifically-proven safety procedures, which is why we are developing these procedures, using them and testing their effects. Ultimately, the number one safety parameter is a surgeon who is paying complete attention — so we want our processes to enhance his or her process, not future distract from it.”
Reference:
Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol era: Analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145(10):978-984. doi:10.1001/archsurg.2010.185