AAOS Bulletin - August, 2006

AAOS Member Patient Safety Survey: A first look

By David A. Wong MD, MSC, FRCS(C)

In the summer of 2005, the AAOS Patient Safety Committee—through the AAOS department of research—conducted a survey of the AAOS membership concerning observed incidents of medical errors during the previous six months of practice. The survey was performed to gauge the frequency of errors in orthopaedic practice and to classify incidents according to two different systems—one developed by another surgical society and the other by the Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum (JCAHO/NQF).

The American Academy of Otolaryngology—Head and Neck Surgery surveyed its members about medical errors, resulting in a peer-reviewed stratification of the incidents of medical error into 16 general categories (e.g., errors in diagnosis, technical errors, medication errors, communication problems).1 The most frequently identified errors were found in the technical (19.3 percent), medical management (13.7 percent) and testing (10.4 percent) categories. Wrong-site surgery made up 6.1 percent of the incidents (Table 1).

The AAOS survey was modeled on the otolaryngology study, in which key questions were open-ended and descriptive. Orthopaedic surgeons’ responses were classified according to the same 16 categories. Additionally, the orthopaedic incidents were mapped to the patient safety taxonomy developed by the

JCAHO and adopted by the NQF.2 The JCAHO/NQF taxonomy is a more detailed classification, addressing issues such as the location of the incident and extending to prevention strategies. The AAOS survey represents the first large-scale application of the JCAHO/NQF taxonomy and will serve to validate and refine the taxonomy process.

Equipment, communication errors top list

Of the 5,540 surveys that were sent to a subgroup of AAOS members, 957 members responded, describing a total of 483 incidents. The highest incidence of orthopaedic errors was in the equipment (30 percent), communication (26 percent) and technical (13 percent) categories. Wrong-site surgery accounted for 9 percent of orthopaedic incidents (Table 2).

There are several interesting “first-look” observations from the initial overview of the data. For orthopaedics, the top two categories of error—equipment and communication—accounted for more than 50 percent of the incidents.

The fact that equipment errors topped the list in our heavily instrument- and implant-dependent specialty is perhaps not very surprising. However, the descriptive nature of the survey reports offers an opportunity for further subanalysis of the incidents into broad classifications such as instrument versus implant problems. In addition, the Patient Safety Committee will look into issues such as availability versus technical failures and whether an incident adversely affected patient care.

Communication errors were the second most frequently reported problem. This high ranking seems to validate the Academy’s efforts to make education in professional communication a major priority for AAOS continuing medical education efforts.3 Subanalysis is ongoing in this area as well. Additional information will be made available on whether communications problems arose in specific locations (e.g., OR versus hospital floor) and between various members of the medical team (such as physicians, nurses, scrub techs and industry representatives).

The reports of wrong-site surgery incidents—despite the Academy’s efforts to encourage participation in the AAOS Sign Your Site4, 5 program and the JCAHO Universal Protocol6, 7—are a definite concern. (Incidents of wrong-site surgery accounted for 9 percent of orthopaedic errors.) The JCAHO Universal Protocol became mandatory on July 1, 2004,8 the summer before the survey was administered. Reports by orthopaedists of wrong-site surgery incidents during the previous six months of practice thus encompass a time frame during which the Universal Protocol was in place. Marking the surgical site is one of the three key elements of the Universal Protocol, which includes patient identification, surgical-site marking and “time out.” The mandatory nature of the Universal Protocol should ultimately result in additional compliance. However, the Patient Safety Committee will be considering additional initiatives to help eliminate wrong-site surgery.

An early overview of the AAOS Patient Safety Survey indicates several areas where the fellowship needs to be attentive. Equipment was the most frequently encountered source of orthopaedic error. The “time-out” portion of the Universal Protocol specifically targets this problem—giving the surgeon the opportunity to verify that the appropriate instrumentation and implants are available and in good working order. The fact that “communication incidents” rank as the second most frequent source of error should encourage the fellowship to take advantage of the AAOS communication workshops.3 Finally, the ongoing reports of wrong-site surgery suggest that we must be absolutely committed to compliance with the integrated “Sign Your Site” and Universal Protocol programs.

David A. Wong MD, MSC, FRCS(C) is chair of the AAOS Patient Safety Committee.


1. Shah R, Kentala E, Healy G, Roberson D. Classification and Consequences of Errors in Otolaryngology. Laryngoscope 2004; 114:1322-1335.

2. Standardizing a Patient Safety Taxonomy. National Quality Forum.

3. Misovic K. Orthopaedists go to the head of the class in communication. AAOS Bulletin, April 2006.

4. AAOS Advisory Statement on Wrong Site Surgery.

5. Sign Your Site Audio/Visual Program.

6. JCAHO Universal Protocol for Prevention of Wrong Site, Wrong Procedure and Wrong Person Surgery.

7. Guidelines for Implementation of the JCAHO Universal Protocol.

8. Wong DA. Surgical Site Marking Comes of Age. AAOS Bulletin, April 2004.



Medical management




Surgical plan




Wrong-site surgery


Table 1. Ranking of otolaryngology errors by percentage of total incidents









Wrong-site surgery


Imaging problem


Table 2. Ranking of orthopaedic errors by percentage of total incidents.

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