April 2004 Bulletin

AAOS conducts critical incident research

By Carolyn Rogers

One of the Academy's goals is to ensure that members and their staffs have tools at their disposal to minimize problems related to clinical diagnosis, surgery and patient recovery.

In line with this ongoing commitment, and at the recommendation of the AAOS Medical Errors Oversight Panel, the Academy recently conducted a qualitative research study to assess the types of critical incidents that are of concern to orthopaedists and orthopaedic nurses, and to solicit recommendations about ways the Academy can help minimize or prevent these incidents.

Axxiom Healthcare Alliance, a marketing research firm, was hired to conduct confidential telephone interviews with AAOS fellows and members of the National Association of Orthopaedic Nurses. A total of 20 interviews—10 with orthopaedists and 10 with orthopaedic nurses—were conducted from Sept. 4-25, 2003.

AAOS research and scientific affairs and market research staff created the discussion guides with input from Axxiom. The 30-to-40-minute interviews were audiotaped and transcribed.

The findings
In general, AAOS fellows and orthopaedic nurses believe that the occurrence of “true” critical incidents is rare. Instead, so-called near misses and medical errors often are attributed to external factors such as “acts of God,” unexpected mechanical failures, and/or unforeseeable or peculiar clinical scenarios.

Overall, the critical incidents most often reported by fellows and nurses involved three key areas:

PCA-related problems arise when a maximum dose or time period is not programmed in the device, thereby permitting the patient and/or the patient's family to overdose the medication. They are generally attributed to nurse oversight.

Delayed administration of prophylactic antibiotics, while undesirable, is viewed as a minor issue that stems from changes in the surgical schedule.

Although medical professionals are well aware of the difficulties inherent in managing anticoagulants, they may not be aware that patients are taking these medications. Still, patient outcomes are rarely negatively affected, respondents say.

With respect to misdiagnosis, respondents say that emergency department physicians, radiologists and (to a lesser extent) primary care physicians often underestimate or miss clinical signs and imaging/lab evidence of orthopaedic damage. To offset these problems, most of the fellows say they now opt to read and interpret test results and scans themselves. Likewise, due to critical incidents in the intraoperative setting involving wrong/incomplete implantable components, orthopaedists typically make a commitment to check these components personally prior to surgery.

Although there was no consensus among respondents about the stage at which critical incidents are most likely to occur, many readily identified the intraoperative phase as the stage where the most critical or significant events can happen.

The majority of orthopaedists and nurses believe that the frequency of critical incidents—especially wrong-site surgery—has declined over the past three years. Many credit the implementation of site-marking programs, such as “Sign Your Site,” for this drop.

As might be expected, participants believe that additional initiatives created by the Academy would be of value in further containing critical incidents. Specific programs of interest include:

Conclusions
According to Axxiom, the findings suggest that the threat of litigation may play a role in increased vigilance among orthopaedists, orthopaedic nurses and hospital staffs. Further, the success of the “Sign Your Site” program has led to the use of checklists and other means to prevent critical incidents from occurring. Still those incidents that do occur are often the result of non- or miscommunication, or are due to undertrained non-orthopaedic health care professionals.

Next Steps
AAOS research staff has created a database with the critical incident and near-miss information. The Patient Safety Committee will review the database at its next meeting. Future educational projects will be defined after data analysis.


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