February 2003 Bulletin

Patient Safety Coalition holds first meeting

On November 22, 2002 an unprecedented gathering of orthopaedic organizations was held in Rosemont, Ill. to address the issue of patient safety. They were brought together by a common interest in reducing the number of medical errors and fostering an environment of patient safety throughout the United States.

Their aim was to form a Patient Safety Coalition to develop and implement programs that promote safety in all aspects of orthopaedic care. This coalition’s primary goal is the enhancement of knowledge about safe medical practices by both orthopaedic surgeons and patients.

The meeting served as a summit, providing a platform for a formal coalition of orthopaedic groups to address the issue of patient safety. It brought together representatives from a variety of orthopaedic groups, including orthopaedic specialty societies, AAOS councils, state orthopaedic societies, Board of Councilors, National Association of Orthopaedic Nurses, the BONES Society, orthopaedic academic training programs, Orthopaedic Corporate Advisory Council, OREF and the military.

The meeting was chaired by David K. Wong, MD, chair of the recently formed AAOS Patient Safety Committee. James H. Herndon, MD, 2003-04 AAOS President served as co-chair.

Coalition is needed

In his opening remarks, Dr. Wong described some of the patient safety activities AAOS is currently involved in: the "Sign Your Site" program; the "Take Care! Patient Safety is No Accident" public awareness campaign; the Evidence Based Practice Committee; membership in the National Quality Forum; participation in the Medicare Patient Safety Monitoring system and development of a total joint registry, to name a few.

However, he noted, "Patient safety is an initiative so broad it cannot be accomplished by the AAOS alone and the participation of the assembled organizations is needed in order to be successful. We must come together on common ground to accomplish our goals.

"Several organizations have already embarked upon their own initiatives," continued Dr. Wong. The North American Spine Society has introduced the Sign, Mark & X-ray (SMaX) program, for example, a new patient safety tool designed to help prevent wrong-site spine surgery. In addition, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services have joined forces in a campaign that urges patients to ‘Speak Up’ to prevent health care errors. We all need to support and participate in these programs."

Why orthopaedists should care

The tone of the meeting was set with an overview of patient safety issues by Dr. Wong, followed by a presentation on "Medical Errors in Orthopaedics: Practical Pointers for Prevention," by Drs. Wong, Herndon and past AAOS President S. Terry Canale, MD.

In addition, Dr. Herndon spelled out several specific reasons for the orthopaedic profession to look closer at patient safety, including JCAHO-cited sentinel events in orthopaedics:

Open mike

A highlight of the meeting was an ‘open mike’ session, in which representatives of several participating groups described their own current or planned patient safety activities and offered ideas for future joint projects. Speakers included Paul Anderson, MD, and Sohail Mirza, MD, of the Cervical Spine Research Society; Hal Blank of the American Society of Orthopaedic Physician Assistants; Peter J. Fowler, MD, of the American Orthopaedic Society for Sports Medicine; Geri Tierney, BSN, RN, ONC, president-elect of NAON; Jeffrey Thomson, MD, of the Pediatric Orthopaedic Society of North America (POSNA); and, John V. Hill, MD, of the California Orthopaedic Society.

Based upon the general consensus of Coalition participants, the priorities for 2003 will be for the Coalition to serve as a communications vehicle and patient safety information dissemination point. Consequently, the AAOS will set up a Patient Safety Coalition listserv, an electronic Bulletin Board, a speakers’ bureau and will develop other educational tools such as a power point presentation designed to educate health care professionals on patient safety.

Benefits are clear

In his closing remarks, Dr. Wong told attendees, "Leadership is needed on the issue of patient safety, particularly in the areas of communication and education, areas in which our musculoskeletal associations are in a unique position to serve. Ultimately, every orthopaedic patient will benefit from the heightened awareness of patient safety.

"Every member of the coalition will also benefit by being part of a group committed to the reduction of potential medical errors. It is my hope that, working together, we can create the ‘gold standard’ for patient safety."

Dr. Herndon added, "This patient safety initiative is one of the most significant things doctors can do today."

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