Abstract
Background
There has been widespread interest in medical errors since the publication of ‘To Err is Human’ by the Institute of Medicine in 1999. The Patient Safety Committee of the American Academy of Orthopaedic Surgeons has compiled results of a member survey to identify trends in orthopaedic errors that would help direct quality assurance efforts.
Methods
Surveys were sent to 5,540 Academy fellows; 917 were returned (response rate 16.6%) with 53% (483/917) reporting an observed medical error in the last 6 months.
Results
A general classification of errors showed equipment (29.0%) and communication (24.7%) errors with the highest frequency. Medication errors (11.4%) and wrong site surgery (5.6%) represented serious potential patient harm. Two deaths were reported, both involving narcotic administration errors. By location, 78% of errors occurred in the hospital (surgery suite 54%, patient room/floor 10%). The reporting orthopaedic surgeon was involved in 60% of the errors, nurses in 37%, another orthopaedic surgeon in 19%, other physicians in 16% and housestaff in 13%. Wrong site surgeries involved the wrong side 59%, another wrong site (e.g. wrong digit on the correct side) 23%, the wrong procedure 14%, on the wrong patient 4% of the time. The most frequent anatomic location was the knee and fingers/hand (both 35%), the foot/ankle 15%, followed by distal femur 10% and the spine 5%.
Conclusion
Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance efforts and more refined research can be addressed towards areas with higher error occurrence (equipment, communication) and high risk (medication, wrong site surgery).
