June 2003 Bulletin

Board of Directors holds workshop on patient safety

The Board of Directors held a three-day workshop in April that focused on developing strategies for improving orthopaedic patient safety. AAOS President James H. Herndon, MD, chaired the workshop, which addressed such questions as:

Workshop participants heard presentations by nationally recognized experts in the field of patient safety, including Michael L. Millenson, Mervin Shalowitz, MD Visiting Scholar at Northwestern University’s Kellogg Graduate School of Management; Michael Leonard, MD, Physician Leader for Patient Safety, Kaiser Permanente; John Gosbee, MD, MS, Human Factors Engineering and Healthcare Specialist at the Veteran’s Administration National Center for Patient Safety; and Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health.

System change needed

In his opening remarks to workshop participants, Dr. Herndon noted that when a medical error occurs, physicians fear punishment, professional censure and litigation. Much of this is due to the prevailing blame-and-shame attitude that exists in today’s healthcare environment. "However, most errors happen as a result of limited resources and staff, lack of time and competing priorities," he asserted. "These are system problems that can and should be corrected. I believe that teamwork and better communication are essential to reducing healthcare errors."

Workshop keynoter, Michael L. Millenson, echoed Dr. Herndon’s comments adding, "The key to patient safety is to make a commitment to evidence, ethics and effective actions. We need to determine what changes to undertake as individuals and professional societies . . . The provision of healthcare today results in harm too frequently and fails to deliver potential benefits. Trying hard will not work, but changing the systems of the provision of care will." (Note: Mr. Millenson’s remarks are printed in their entirety beginning on page 47.)

Michael Leonard, MD, also emphasized that collaboration and effective communications are the key contributors to culture change within hospitals in general and operating rooms (OR) in particular. He noted that the overwhelming majority of untoward events involved communication failure. "In every case, somebody knows there’s a problem but can’t get the rest of the team focused on fixing it," he said. "If the problem is that the clinical environment has evolved beyond the limitations of individual human performance, the answer is to collaboratively monitor one another in order to keep the environment safe."

Dr. Leonard advocated a preoperative briefing to help keep everyone on the same page. "Verify the patient and the procedure. Introduce yourself and call staff members by name to increase familiarity. Ask for input and make eye contact. Encourage ongoing monitoring and crosschecking. The surgeon needs to assure that everyone in the OR feels comfortable stating, ‘I’m concerned, let’s address the problem.’"

Lucian Leape, MD, a world-leader in the patient safety movement, told participants, "The idea that medical errors are caused by bad systems is a new and transforming concept. Medical injuries are not inevitable and most are preventable. While it may not be your fault, it is your responsibility to help change the system. It is easier to change the system than to change people."

Recommendations

Seven general recommendations resulted from the workshop:

  1. The AAOS Council on Research should sponsor research on root cause analysis.
  2. The AAOS should review orthopaedic medical legal claims for causes of error.
  3. Through the Orthopaedic Device Forum, AAOS should work to change the culture of blame and shame associated with medical errors.
  4. The Council on Research should develop performance measures for non-steroidal medications and certain over-the-counter medicines and identify potential harm to patients.
  5. The AAOS should review the successes/problems of hospitals that have implemented CPOE (Computerized Physician Order Entry) and compare outcomes/error rates before and after implementation.
  6. The AAOS should determine the error rates when "pre- and post-op huddles"–operating room team briefings and de-briefings–occur and look at outcomes before and after the briefing protocols were implemented.
  7. AAOS should focus on residents and Fellows who do not comply with the "Sign Your Site" program and determine why.

In his remarks concluding the workshop, Dr. Herndon said, "The AAOS is in a good position. By taking on the cultural issue, the AAOS is moving from training to actual practice. If we don’t implement these changes ourselves, we will lose control of our professional life to regulators, lawyers and payers."


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