JBJS Surveys Physicians about Surgical Errors
BY LAUREN UZDIENSKI, MARCH 19, 2009
In a survey of 917 members of the AAOS, more than half reported observing surgical errors in the past six months. The study, published in JBJS, highlighted some of most frequent mistakes and described initiatives by the AAOS and others to reduce preventable errors.
Survey questions covered where and at which points in the surgical cycle the error occurred; who was involved; the type of error and its effect on the patient; and whether it resulted in litigation (this happened in 4% of cases).
Comprising 29% of incidents, the most commonly reported error was related to a problem with equipment. Instrumentation was reported to cause an error about twice as often as an implant (63% of incidents compared to 32%). Implant errors usually involved a missing implant (43% of these cases) or having the wrong implant (29%). Implants breaking either pre- or intraoperatively were fairly rare occurrences.
Communication errors comprised 25% of responses, either in the form of written, verbal or dictated information or, in 23% of these cases, a failure to communicate. 19% of these incidents resulted in a near miss involving the patient, and the error resulted in a negative outcome (including delayed surgery or a revision) in 33% of these cases. 47% resulted in no harm to the patient.
There were 27 reports of wrong-site surgery. 59% of these were wrong-side. Other wrong-site problems included right side, wrong location (e.g., the wrong finger on a the right hand), wrong procedure and even wrong patient (though this happened only once among survey respondents).
The most serious errors were medication errors, which occurred in eight patients described by survey respondents. Of these, two deaths were reported related to narcotics given in the hospital ward, four patients required intervention to sustain life and two sustained permanent harm.
This study showed that errors do occur during orthopedic surgery, and the AAOS has championed a number of programs to reduce their frequency. Regarding wrong-site surgery, the group has promoted the Sign Your Site program to encourage the surgeon to initial the procedure site. NASS has something similar in the Sign, Mark and X-Ray initiative. Calling a "time out" before an incision provides another opportunity to double-check the patient and equipment by verifying allergies, antibiotics, records, imaging and equipment.
The study's authors report that there has been "resistance" to adopting patient safety protocols and that the introduction of these programs can represent a culture shift in some ORs. While this survey shows that about half of all reported errors don't result in any harm to the patient, it also highlights room for improvement in patient safety and helps to illustrate how outcomes can benefit from relatively simple measures.
