February 2003 Bulletin

New patient safety program moves forward

Includes member communications, education, research and advocacy projects

By David A. Wong, MD, MSc, FRCS(C), Chair, Patient Safety Committee

The Sign Your Site program has, heretofore, been the primary focus of AAOS patient safety initiatives. Recently, however, the Board of Directors has decided to broaden the Academy’s efforts in the patient safety area. These efforts are centered within the newly established Patient Safety Committee.

The Committee first met September 20, 2002, charged with developing a comprehensive business plan for the AAOS designed to promote orthopaedic patient safety and to reduce as completely as possible the potential of medical errors that could occur in orthopaedic practice. To accomplish this, the committee began by reviewing and assessing current AAOS patient safety and medical error reduction activities. From this discussion, an action plan for a series of new patient safety initiatives was developed. The Board of Directors subsequently approved the plan and it will be implemented over a two-year period.

In addition to further promotion of the "Sign Your Site" program, the plan includes 10 projects that are organized in the areas of member communication, education, research, advocacy and outreach:

Member Communication

A key part of the Academy’s new patient safety effort is the development of a mechanism that will quickly notify AAOS Fellows of urgent news regarding medical devices, biologics and drugs that could impact patient safety. Presently, we have been able to accomplish this through a combination of e-mail Member Alert messages, notices in Headline News and fax blasts. The first such alert concerned contamination of allografts after two patient deaths were reported in Minnesota.

We now propose to build upon this existing effort and create a more formal communication process for informing AAOS members about urgent patient safety news. This will be accomplished through dissemination of an e-mail/fax service called Patient Safety Member Alert. Notices will be distributed separately from any other AAOS publication and will be dedicated solely to informing members about urgent patient safety news. It will be distributed on an as-needed basis.

Less urgent, more didactic, informational items will be posted on the patient safety section of "Your Orthopedic Connection", the Academy’s patient education Web site. The site will be available to both physicians and patients. More comprehensive data can be posted via this means. Additional Web links to outside sites of interest will be provided as appropriate.

To keep members informed about the progress of our work in the patient safety arena, we also propose to develop a quarterly e-newsletter called Patient Safety News.

A fairly unique component in the communications area will be the development of vignettes for "Physician/ Patient Communications Training". This is an extension of the existing AAOS Communications Skills Mentoring Program that is done in partnership with the Bayer Institute to advance orthopedic surgeon/patient communication. These vignettes will be offered as part of a series of interactive workshops offered at the local, state and regional levels and will target both practicing clinicians and residents.


A project team has begun work on a "Patient Safety Curriculum" targeted towards orthopedic residency training programs. Topic areas such as the history and scope of patient safety concerns, the role of complex medical systems as well as systems solutions will be included.

In addition, AAOS Fellows will see educational materials in the form of symposia and instructional courses at the annual meeting, literature and Web based publications and discussion at AAOS sponsored CME courses.

The Patient Safety Committee is also working with the Evidence Based Practice Committee to develop a "Positive Practices" program to identify practical steps that surgeons can incorporate into their practices to enhance patient safety. This includes ideas such as pre-printed post op order forms, computerized medication order systems and bar code identification of medications etc.

A public education campaign entitled "Patient Safety Is No Accident" is ready to be launched. This initiative will include airport billboards, press releases and postings on the "Your Orthopedic Connection" Web site.


At the 2004 AAOS Annual Meeting, focus groups of Chief Orthopedic Residents will be convened as a first step in "Near Miss Research". This is analogous to the initial data gathered by the aviation industry in the late 1900’s. This information helps identify areas of concern, systems problems and cultural issues impacting patient safety. Themes where more in-depth research might be helpful can be identified.

The area of "Ambulatory Surgery/ Office Errors" will also be researched. To date, most patient safety reviews have been in the hospital setting. Issues such as prescription interaction, identification of herbals and other health supplements with anesthetic and surgical implications as well as surgical site identification, all have application to the outpatient setting.


There have been several legislative proposals to create national or state based medical error reporting systems. The AAOS feels that it is important to include appropriate privacy protections in these systems. The non-punitive "near miss" reporting system in the aviation industry is a good model for medicine. Data collected serves as the basis for educational and remedial efforts when issues are identified.

Pilot projects including voluntary, non-punitive reporting would serve as an ideal trial to determine if worthwhile data could be documented from such systems.


A major initiative of the AAOS Patient Safety program is to help co-ordinate and extend patient safety efforts among professional medical societies involved in care of the musculoskeletal patient. Accordingly, the first meeting of the "Coalition for Patient Safety" was held in November 2002 (see related article on page xx). Representatives from more than twenty societies laid the groundwork for an interactive communication system to reach all physician members of the coalition associations and their patients.


The AAOS has striven to encourage "Best Care" of patients. These additional patient safety projects serve to further that mission. The AAOS has been acknowledged as a leader in the patient safety arena because of its recognition of wrong site surgery and its pro-active "Sign Your Site" (SYS) initiative to address the concern head on. The broad focus of the tasks now beginning will cement the leadership position of the Academy and provide additional safeguards for patients.

David Wong, MD is chair of the AAOS Patient Safety Committee and also serves as President of the North American Spine Society (NASS) and as chair of the NASS Patient Safety Task Force.

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