Medical Errors in Orthopaedics

Wong, David A.; Herndon, James H.; Canale, S. Terry; Brooks, Robert L.; Hunt, Thomas R.; Epps, Howard R.; Fountain, Steven S; Albanese, Stephen A.; Johanson, Norman A.

doi:10.2106/jbjs.g.01439

Cited by 86 publications

(30 citation statements)

References 29 publications

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“…At the minimum, the lack of source imaging should be included as a "hard stop" during the conduct of pre-operative checklist and then during the surgical "time-out" [63,64]. This applies to a variety of potential clinical scenarios, from the one outlined in Clinical Vignette #2 to extremity procedures performed on multiply injured orthopedic patient, to thoracostomy tube, or orthopedic traction pin placement [65,66]. Invasive interventions classified as "wrong site," "wrong patient," or "wrong procedure" are all considered to be "never events" and require mandatory reporting and root cause analysis [19,67].…”

Section: Vignettes In Patient Safety -Volumementioning

confidence: 99%

Wrong-Site Procedures: Preventable Never Events that Continue to Happen

Lin¹,

Wernick²,

Tolentino³

et al. 2018

Vignettes in Patient Safety - Volume 2

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A comprehensive discussion of "never events" or preventable and grievously shocking medical errors that may result in serious morbidity and mortality is incomplete without a thorough analysis of wrong-site procedures (WSP). These occurrences are often due to multiple, simultaneous failures in team processes and communication. Despite being relatively rare, wrong-site surgery can be devastating to all parties involved, from patients and families to healthcare workers and hospitals. This chapter provides a general overview of the topic in the context of clinical vignettes discussing specific examples of WSP. The goal of this work is to educate the reader about risk factors and preventive strategies pertinent to WSP, with the hope of propagating the knowledge required to eliminate these "never events." To that end, the chapter discusses pitfalls in current surgical practice that may contribute to critical safety breakdowns and emphasizes the need for multiple overlapping measures designed to improve patient safety. Furthermore, updated definitions regarding WSP are included in order to better characterize the different types of WSP. Most importantly, this chapter presents evidence-based support for the current strategies to prevent wrong-site events. A summary of selected recent wrong-site occurrences is also provided as a reference for researchers in this important area of patient safety.

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Section: Vignettes In Patient Safety -Volumementioning

confidence: 99%

Wrong-Site Procedures: Preventable Never Events that Continue to Happen

Lin¹,

Wernick²,

Tolentino³

et al. 2018

Vignettes in Patient Safety - Volume 2

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“…Hand surgeons are most familiar with intraoperative errors. Not to be overlooked are medical errors occurring outside the operating room, which may be a result of failing to recognize an injury, treatment delays, medication errors, misdiagnosis, and communication failures (3, 8, 9). A variety of error classifications have been proposed.…”

Section: Medical Errors In Hand Surgerymentioning

confidence: 99%

“…A variety of error classifications have been proposed. The Joint Commission on the Accreditation of Healthcare Organizations uses a detailed taxonomy system which categorizes errors based on impact, type, domain, cause, prevention, and setting (3). Little has been published about classifying medical errors occurring in hand surgery.…”

Section: Medical Errors In Hand Surgerymentioning

confidence: 99%

“…Since the IOM’s publication, significant effort has been directed towards system-wide changes to effectively address patient safety concerns (1, 2, 3, 4). Within orthopaedic surgery, several campaigns, such as the “Sign your Site” and the universal protocol, have been implemented to curb wrong-site surgery (3, 5, 6).…”

Section: Introductionmentioning

confidence: 99%

“…Within orthopaedic surgery, several campaigns, such as the “Sign your Site” and the universal protocol, have been implemented to curb wrong-site surgery (3, 5, 6). Less attention, however, has been directed at educating and guiding surgeons on how best to approach medical errors.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Addressing Medical Errors in Hand Surgery

Johnson

Adkinson

Chung

2014

The Journal of Hand Surgery

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Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain trust. Further, equipping hand surgeons with a guide for addressing medical errors will promote compassionate patient interaction, help identify system failures, provide learning points for safety improvement, and demonstrate a commitment to ethically responsible medical care.

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