AAOS Exclusive: Orthopedic Surgeons Lead the Way in Patient Safety

In 1997, the American Academy of Orthopaedic Surgeons (AAOS) launched an initiative for patient safety. The organization established a task force to examine the subject of wrong site surgery and to develop a protocol for orthopedic surgeons to prevent even one more incident. The task force determined that an orthopedic surgeon has a 1 in 4 chance of performing a wrong site surgery during a 35-year career. Also in 1997, the Physician’s Insurance Association of America conducted a study covering the insurance payments of 22 different physician insurance companies from across the United States. The study found 225 occurrences of wrong site orthopedic surgery during an eleven year period, from 1985 through 1995. The survey suggests the impact of wrong site surgery on both patient and physician is significant.

So AAOS began the “Sign Your Site” initiative, which was based on a similar program established by the Canadian Orthopaedic Association. The initiative highlighted three actions for patients: a review of the operative procedure with the patient and operating room personnel prior to surgery; a review of the patient’s chart in the operating room prior to surgery; and the patient writing their initials at the operative site. Hence, “sign your site.”

William Robb, M.D., or the Northshore University Health System in Chicago, Ill., and Dwight Burney, M.D., of New Mexico Orthopaedics in Albuquerque, N.M., discussed patient safety with Orthopedic Design & Technology at the 2014 Annual Meeting of AAOS held in New Orleans, La.

In 2004, the AAOS established the Patient Safety Committee (PSC) which, according to AAOS, “interacts with governmental and private organizations such as the Joint Commission, the World Health Organization, and the Centers for Disease Control and Prevention to develop programs and materials that increase safe practices in orthopedics.

“We’ve made substantive improvements in terms of focus of the program, but there aren’t a lot of data on the subject of patient safety,” said Robb.

There are two types of data that need to be gathered, Robb explained: External and internal. Internal data, of course, is data gathered from physicians and patients. But, as Robb said, “knowing how you’re doing is ok, but it needs to be put into perspective.” Therefore, external data that compares data from different institutions from different patients and physicians is necessary to form a complete picture of patient safety.

“The only national registry related to patient safety is the American Joint Replacement Registry, which collects only implant data,” Robb said. “Very soon it will move into quality and safety areas as well as long term outcomes. That kind of data is compelling. Implant data just allows us to identify early failures that might be implant-specific, and helps policy makers make decision about recalls in a timely fashion.”

The American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) collects data for general surgical procedures, Robb went on to say, and there have been orthopedic models that have been underutilized. A November 2013 article by PSC member Gregory H. Sirounian, M.D., noted that following the 2012 Orthopaedic Safety Summit, “several orthopedic-oriented checklists are being developed for pediatrics, adult reconstruction, ambulatory surgery, opioid safety, identification of correct-level spine surgery, and improvements in hip fracture care.”

Burney told ODT that the committee is also heavily focusing its efforts on educating orthopedic surgeons on communication and empathy techniques through its communication skills mentoring program, which it recently expanded.

“The challenge for anyone operating right now is to be highly reliable,” Burney said. “We want to operate the same way that other highly demanding and complex industries operate, such as the airlines industry or the nuclear industry. We want to cultivate a ‘shared mental model’ so we are all on the same page.”

Burney also noted that white patient safety is of concern across all medical specialties, orthopedic surgery is the only field that has made a concerted effort to address the issue.

“In medical school, instruction is largely focused on technical skills,” Robb said. “But to give an egregious example of what could go wrong, you could do a perfect operation on the wrong patient, which would be disastrous. We must create highly reliable, systematic, standardized methods of care that mirror processes incorporated in other complex industries and apply them to our own, and learn which ones work and which don’t.”

An integral part of patient safety is the patients themselves, Burney and Robb said. Late last year AAOS launched a new patient-directed public service campaign “Patient Safety: It Takes a Team” (see image), in which it advised on what patients can do in the interest of their own safety:

• Ask questions—be sure to speak up when you need more information from your doctor;
• Involve a friend or family member in your care;
• Be able to discuss your medical history — such as past surgeries, major illnesses, and family history of medical problems;
• Keep a complete, accurate list of all your medications, including over-the-counter medications, vitamins, and nutritional supplements;
• Tell your healthcare team about your allergies and any past reactions to anesthesia or medications; and
• Ask your doctor for educational resources to help you better understand your condition and treatment options.