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AAOS Hosts Patient Safety Summit

Focus on orthopaedic surgical safety to improve quality

Mary Ann Porucznik

As a leader in the patient safety movement, the AAOS has consistently been proactive in addressing issues surrounding orthopaedic surgical safety. The Surgical Safety Summit being held this month is just one of the Academy’s efforts to help its members improve orthopaedic surgical safety and reduce complications.

“The AAOS Surgical Safety Summit seeks to unify the entire orthopaedic community in prioritizing surgical safety as a critical opportunity to improve surgical care of orthopaedic patients,” saidWilliam J. Robb III, MD, chair of the Patient Safety Committee, which organized the Summit. “The Summit’s focus is on enhanced surgical team communication and the development, implementation, and validation of surgical processes targeted to reduce significant orthopaedic complications.”

Summit participants represent the range of orthopaedic specialties—including hand, foot and ankle, joint reconstruction, pediatrics, spine, sports, and trauma. It will also bring together representatives from other surgical specialties, as well as researchers and government representatives, came together to identify and establish active collaborations committed to improving surgical safety and quality.

“We hope the Summit will foster better communication and education among providers and policymakers to improve surgical outcomes,” said Dr. Robb.

The need for vigilance
According to the results of a medical errors study conducted by the AAOS in 2005, more than half of the respondents witnessed one or more medical incidents (defined as an unanticipated, avoidable event) during the previous 12 months. Nearly two thirds of those incidents occurred postintervention, and more than three quarters occurred in the hospital. Of hospital-based incidents, more than half (52 percent) occurred in the operating room (OR).

Approximately 25 percent of respondents classified the event as a failure in communication; 20 percent identified it as an equipment and/or instrument problem in the OR.

According to The Joint Commission, wrong site surgeries have been reported by one in five hand surgeons, and by one in four orthopaedic surgeons in practice for more than 25 years. Because error reporting is voluntary, however, the true extent of the problem is unknown. Such errors frequently result in medical liability lawsuits, and 84 percent of orthopaedic wrong-site surgery claims end with a payment to the plaintiff.

Although the AAOS has promoted a “Sign Your Site” program since 1997, studies indicate that surgeons sign the site only 56 percent of the time, and only 38 percent of surgeons use their initials. The Universal Protocol, implemented in 2004 by The Joint Commission, calls for marking the surgical site and verifying the patient, procedure, and surgical site during a preoperative “time-out.”

“After more than 10 years of attempting to improve patient safety with a systems approach, medical errors and adverse events are still too common,” noted James H. Herndon, MD, MBA, AAOS past president and chairman emeritus of the Partners department of orthopaedic surgery at Massachusetts General Hospital, in a recent interview with AAOS Now. Dr. Herndon will deliver the keynote address at the 2012 AAOS Patient Safety Summit.

Patient safety in 2012
The following 2012 National Patient Safety Goals are particularly applicable to orthopaedic surgery and will be addressed during the AAOS Patient Safety Summit:

Identify patients correctly—use at least two ways to identify patients to make sure that each patient gets the correct medicine and treatment
Improve staff communication
Prevent infection—use proven guidelines to prevent infection after surgery
Prevent mistakes in surgery—make sure that the correct surgery is performed on the correct patient and at the correct place on the patient’s body; mark the correct place on the patient’s body where the surgery is to be performed; pause before the surgery to make sure that a mistake is not being made

A variety of surgical safety programs—including those sponsored by The Joint Commission, the Centers for Medicare & Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC)—will also be reviewed during the Summit, and work groups will addressed specific safety issues within orthopaedic specialties. During the second day of the summit, the focus will be on communications, relationships, and establishing a culture of safety. Next steps will be determined.

Presenters at the summit included government representatives such as Michael Rapp, MD, JD, director of the quality measurement and health assessment group, CMS office of clinical standards and quality; Daniel Pollock, MD, chief of the surveillance branch, division of healthcare quality promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC; and James Battles, PhD, senior policy maker for the Comprehensive Unit-Based Safety Program at the Agency for Healthcare Quality and Research.

Additional presenters include Dwight Burney, MD, chair of the AAOS Communications Mentoring Project Team; David Flum, MD, MPH, medical director of the Washington State Surgical Care Outcomes Assessment Program; David Hoyt, MD, executive director of the American College of Surgeons; Michael Leonard, MD, physician leader of patient safety at Kaiser Permanente; William Obremskey, MD, MPT, chair of the Orthopaedic Trauma Association Evidence-based medicine Committee; Kit Song, MD, chief of staff at Shriners Hospital for Children, Los Angeles; John Webster, MD, physician consultant with HTT, a global provider of teamwork and communication training within health care; and John R. Tongue, MD, AAOS president. Watch for additional coverage of the AAOS Patient Safety Summit in the September issue of AAOS Now.

Mary Ann Porucznik is managing editor of AAOS Now; she can be reached at porucznik@aaos.org

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