AAOS Bulletin - October, 2005

Avoiding medical errors: The decision is yours

Patient safety tip

By James H. Herndon, MD

Since the Institutes of Medicine issued its report To Err is Human in 1999, leaders in the field of patient safety have repeatedly stated that physicians have been relatively silent. Even on such a simple issue as the surgeon’s signing the patient’s surgical site, physicians have been resistant; many still delegate the responsibility to others or refuse to sign the site.

There are consequences to our profession’s lack of leadership and commitment to reduce and eliminate medical errors. Society, third-party payers and government are moving to the forefront and using two strategies to reduce errors: Increased regulation of physicians and hospitals and pay-for-performance. This is a move toward paying “bonuses” or larger fees to hospitals and physicians who meet certain quality and efficiency (e.g. reduced costs) standards.

AAOS members need to take a leadership role in reducing errors and improving patient safety. The following actions have all been proven effective; we all need to implement them in our practices.

• Develop and use guidelines. Adopt best practices, accept standards, decrease variation in care and eliminate unnecessary care. Remember, the patient is the center of our care.

• Use physician order entry systems and electronic medical records.

• Monitor and report your outcomes.

• Avoid repeating mistakes that others have made. Learn what those mistakes are from the AAOS closed claims data or other studies and avoid them.

• Follow up on all laboratory tests and imaging studies ordered and inform the patient of the results yourself.

• Stay current on new knowledge and skills. Maintain your competence and fulfill the maintenance of certification requirements. This recommendation is especially directed at older physicians who have been in practice for many years.

Safety in surgery

• Sign the surgical site—YOURSELF.

• Don’t work when excessively tired.

• Support adequate nursing levels in your institutions.

• Support disclosure of errors and near misses. Help to establish mandatory reporting and root cause analysis of all errors and near misses.

• Decrease the incidence of infections. Use appropriate perioperative antibiotics and administer them at times to maximize their effectiveness. Follow established guidelines. Wash your hands before examining each patient. Use recommended guidelines for inserting central lines. Don’t wear surgical scrubs to and from work.

• Be certain not to leave instruments/ sponges in patients after surgery. Take an intraoperative X-ray when the counts are wrong, in obese patients, in emergency cases and when the surgical plan has been changed during the procedure.

• In teaching hospitals, change the standard morbidity and mortality conference to one that identifies problems, analyzes problems and implements change to avoid the same errors in the future.

• Use new technology wisely. Adopt an evaluation system and use the Internal Review Board process for new surgical procedures and new technologies on the market. Only after the outcomes and safety of new technologies and new procedures are known should these technologies and procedures be available to all surgeons and their patients.

Patient-centered care

• Adopt and use shared decision making with your patients.

• Avoid communication errors—the most common reason for medical errors—and learn to work in teams.

Finally, our profession needs to protect the public by addressing the problems of impaired or incompetent physicians. Physicians who are behind in their knowledge or skills, impaired or incompetent may need medical attention or remedial training and education. If their performance cannot be improved to meet the level of their peers, they need to be limited or removed from practice so that no harm comes to any patient.

Our profession must establish the standards to support patient safety and physician competency. We must also work through the political and legal process to implement them. Our patients deserve nothing less from us.

James H. Herndon, MD, is chairman emeritus, department of orthopaedic surgery, at Partners Healthcare System Inc., and second past president of the AAOS. He can be reached at jherndon@partners.org

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