AAOS Bulletin - February, 2005

AAOS releases patient safety video

Now on DVD: “Medical Error: A Preventable Complication”

By Carolyn Rogers

The AAOS has produced a glossy new patient safety video—“Medical Error: A Preventable Complication”—the latest initiative from the Academy’s wide-ranging patient safety program.

The professionally produced 18-minute video was filmed on location at Denver’s Presbyterian/ St. Luke’s Medical Center—home to David A. Wong, MD, chair of the AAOS Patient Safety Committee.

Target audience

The new video is directed primarily toward orthopaedic residents and medical students, as well as AAOS fellows, says Dr. Wong. “It will also appeal to institutions that are looking for educational materials geared toward health care professionals involved in procedures that come under the Joint Commission for the Accreditation of Healthcare Organizations’ (JCAHO) new Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The video’s script was drawn from the work of the Patient Safety Committee, AAOS patient safety articles, patient safety tips specific to orthopaedics, and the JCAHO’s new protocol and guidelines.

David A. Wong, MD, (far right) serves as onscreen narrator for the Academy’s new patient safety video.

Serving as the video’s onscreen narrator, Dr. Wong describes the Academy’s “Sign Your Site” program and explains how the AAOS was actively involved in the development of JCAHO’s new Universal Protocol, which went into effect on July 1, 2004.

Dr. Wong also introduces the video’s storyline, which follows an orthopaedic department chair as he shows a new resident “the ropes” on her first day. While touring the orthopaedic department, the doctor carefully explains the patient safety systems that the medical center has implemented.

The video provides an “ideal” approach to implementing the JCAHO protocol, says Dr. Wong.

“Not everything [in the video] will apply to every practice, or every patient-physician interaction,” he says. “But whatever your situation, following a systematic process of care like the one in this program will make it possible to reduce errors and improve outcomes for your patients.”

The video outlines JCAHO’s three-step process for compliance with the protocol:

1. Preoperative verification: Anytime a patient is handed off to another caregiver, records and relevant information must be verified. Ideally, the patient is awake, aware and involved when this happens, although that isn’t always possible. Staff must ensure that all relevant documents and studies are available prior to the start of the procedure. Documents must be reviewed and must be consistent with each other, with the patient’s expectations and with the team’s understanding of the intended patient, procedure and site.

2. Sign Your Site: According to the protocol, the surgical site should be signed at or near the incision site. The mark must be visible after the patient has been prepped and draped. The method of marking and type of mark should be consistent throughout the organization.

3. “Time out”: Once the patient is moved into the operating room, the surgical team must stop everything and call a “time out” before beginning. A final verification of the correct patient, procedure, site and, as applicable, implants, must be conducted, and the entire operative team must participate. The procedure should not be started until all questions or concerns have been raised and resolved.

Hospital, staff, patients play starring role

The medical center gave Dr. Wong and the film crew total access to the facilities, and its staff went out of their way to ensure the four-day shoot went off without a hitch.

“The production of the video was extremely professional, and we had great cooperation from our CEO and the heads of the operating and recovery rooms,” Dr. Wong says. “The production crew worked with our public relations staff to put together an amazingly efficient shooting schedule that enabled us to use the facility without disrupting the normal flow of the hospital.”

Video producer Bill Stokes (left) looks on as Dr. Wong tapes part of the video narration.

Although professional actors played the three leads, Presbyterian/St. Luke’s staff members have numerous small parts and “cameo” appearances throughout the video. Even the patients seen in the background are “real.”

“The patients were so excited to be part of the filming,” Dr. Wong said. “All they wanted for payment was a copy of the video!”

Video distribution

The video—which premiered at the AAOS patient safety booth at the Annual Meeting in Washington, D.C.—will be distributed in several ways. First, a DVD will be sent to all residency program chiefs, as well as to allied medical organizations, state orthopaedic societies, specialty societies and national patient safety organizations. 

“Medical Error: A Preventable Complication” also will be screened at all Orthopaedic Learning Center courses in 2005, during the breakfast prior to the course. The video also will be used, as appropriate, at regional JCAHO meetings on eliminating wrong-site surgery.

Soon, the video will be accessible online via:

• The AAOS patient safety Web site (http://www.patientsafety.aaos.org/)

• Orthopaedic Knowledge Online (http://www.aaos.org/oko)

• A link in the AAOS Residents’ E-letter (subscribe at: http://www3.aaos.org/memdir/academic/sub_news.cfm)

In addition, with several states having recently instituted rules requiring that physicians earn a certain number of CME hours in patient safety before they can renew their medical licenses, the AAOS is working on a program that will enable physicians to watch the video and perform a self-assessment exam for CME credit, according to Dr. Wong.

AAOS members who are involved in teaching programs for medical students or residents may also wish to obtain a copy of the DVD for their libraries. For more information, please contact Lexine Cramm at cramm@aaos.org

Thank you

The Academy extends its thanks to Denver’s Presbyterian/St. Luke’s Medical Center, The Denver Spine Center, Bill Stokes Productions in New York and the Bayer Institute for Healthcare Communication for their invaluable contributions to the production of this video.

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