Patient safety in North America: Beyond "operate through your initials" and "sign your site"

Journal of Bone and Joint Surgery

Volumn 91, Issue 6, 2009, Pages 1534-1541

  Wong, David A ^a   Lewis, Brendan ^b   Herndon, James ^c   Martin, Claude ^d   Brooks, Robert ^e  

^a Denver Spine   (United States)

^b Station Main   (Canada)

^c MASSACHUSETTS GENERAL HOSPITAL   (United States)

^d CMAJ   (Canada)

^e Delmarva Foundation for Medical Care   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CANADA; CLINICAL PROTOCOL; CONFERENCE PAPER; HEALTH CARE ORGANIZATION; HUMAN; INSURANCE; LEGAL LIABILITY; MEDICAL EDUCATION; MEDICAL ERROR; MEDICAL PROFESSION; MEDICOLEGAL ASPECT; OPERATING ROOM; ORTHOPEDIC SURGERY; PATIENT SAFETY; PHYSICIAN; PRIORITY JOURNAL; REOPERATION; SURGEON; SURGICAL ERROR; SURGICAL MORTALITY; SURGICAL PATIENT; UNITED STATES; WORLD HEALTH ORGANIZATION; CLINICAL PRACTICE; FEMALE; HEALTH CARE QUALITY; MALE; MEDICAL SOCIETY; METHODOLOGY; NORTH AMERICA; ORTHOPEDICS; PATIENT ADVOCACY; REVIEW; RISK ASSESSMENT; SAFETY; STANDARD;

FEMALE; HUMANS; MALE; MEDICAL ERRORS; NORTH AMERICA; ORTHOPEDIC PROCEDURES; ORTHOPEDICS; PATIENT ADVOCACY; PHYSICIAN'S PRACTICE PATTERNS; QUALITY ASSURANCE, HEALTH CARE; RISK ASSESSMENT; SAFETY MANAGEMENT; SOCIETIES, MEDICAL;

EID: 67649890815     PISSN: 00219355     EISSN: None     Source Type: Journal    
DOI: 10.2106/JBJS.H.01462     Document Type: Conference Paper

References (37)

1. Statement of the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons on patient safety and the elimination of medical error. Testimony before the Commerce Subcommittees on Health and the Environment and Oversight and Investigations and the Veterans Affairs Subcommittee on Health. US House of Representatives. 2000 Feb 9.
2. Herndon JH. One more turn of the wrench. J Bone Joint Surg Am. 2003;85:2036-2048
3. Wong DA. Spinal surgery and patient safety: a systems approach. J Am Acad Orthop Surg. 2006;14:226-232 (Pubitemid 44916667)
4. Gallagher TH, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, Fraser VJ, Levinson W. US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605-1611 (Pubitemid 44232368)
5. Cowell HR. Wrong site surgery. J Bone Joint Surg Am. 1998;80:463.
6. Furey A, Stone C, Martin R. Preoperative signing of the incision site in orthopaedic surgery in Canada. J Bone Joint Surg Am. 2002;84:1066-1068 (Pubitemid 34907259)
7. Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003;85:193-197
8. DiGiovanni CW, Kang L, Manuel J. Patient compliance in avoiding wrong-site surgery. J Bone Joint Surg Am. 2003;85:815-819 (Pubitemid 36548628)
9. Lewis BD. Initial evidence: reduced levels of wrong sided surgery. COA Bull. 2002:10.
10. Canale ST, DeLee J, Edmonson A, Fountain SS, Weiland AJ, Bartholomew L, Thomason J, Olds Glavin K, Wieting MW, Heckman JD, Gelberman RH. The American Academy of Orthopaedic Surgeons report of the task force on wrong-site surgery, 1998. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1998.
11. American Academy of Orthopaedic Surgeons. Information statement: wrong-site surgery. http://www.aaos.org/about/papers/advistmt/1015.asp. Accessed 2008 Jun 28.
12. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
13. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384
14. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261-271
15. Wong D, Herndon J, Canale T. An AOA critical issue. Medical errors in orthopaedics: practical pointers for prevention. J Bone Joint Surg Am. 2002;84:2097-2100
16. Wong DA, Herndon JH, Brooks RL, Hunt TR, Epps HR, Fountain SS, Albanese SA, Johanson NA. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am. 2009;91:547-557
17. The Joint Commission. Universal protocol for preventing wrong site, wrong procedure and wrong person surgery. http://www.jointcommission.org/ PatientSafety/UniversalProtocol/. Accessed 2008 Jul 8.
18. The Joint Commission. Implementation expectations for the universal protocol for preventing wrong site, wrong procedure and wrong person surgery. http://www.jointcommission.org/NR/rdonlyres/DEC4A816-ED52-4C04-AF8CFEBA74A732EA/ 0/up-guidelines.pdf. Accessed 2008 Jul 8.
19. World Health Organization World Alliance for Patient Safety. Safe surgery saves lives: the second global patient safety challenge. http://www.who.int/ patientsafety/safesurgery/en/. Accessed 2008 Jun 28.
20. Wright PH. Committee on Orthopaedic Practice and Economics (COPE) position paper on wrong sided surgery in orthopaedics. 1994; updated 2005 Nov 26. http://www.coa-aco.org/en/library/health-policy/wrong-sided-surgery-in- orthopaedics.html. Accessed 2008 Jul 8.
21. Canadian Medical Protective Association. https://www.cmpa-acpm.ca/ cmpapd04/docs/highlights-e.cfm. Accessed 2008 Jul 8.
22. The Joint Commission. Second wrong site surgery summit: performance of the correct procedure at the correct body site. 2007 Feb 23. http://www.jointcommission.org/NR/rdonlyres/96936A98-D608-4044-B104- 8A1D5423ECBE/0/Synopsis-WSS-II.pdf. Accessed 2008 Jul 8.
23. The Joint Commission. Root cause analysis in health care: tools and techniques, 4th ed. 2009. www.jcrinc.com/Books-and-E-books/Root-Cause-Analysis- in-Health-Care-Tools-and-Techniques-Fourth-Edition/1738. Accessed 2009 Apr 12.
24. Wong D, Mayer T, Watters W, Sims W, Fessler R, Weinstein S, Spivak J, Brant-Zawadzki M, Hayden P. Sign, mark and x-ray (SMaX): prevent wrong-site surgery. http://www.spine.org/Pages/PracticePolicy/ClinicalCare/SMAX/Default. aspx. Accessed 2009 Apr 12.
25. Wong DA. The universal protocol: a one-year update. 2005 Dec. http://www2.aaos.org/aaos/archives/bulletin/dec05/fline11.asp. Accessed 2008 Jul 8.
26. Dovey SM, Meyers DS, Philips RL Jr, Green LA, Fryer GE, Galliher JM, Kappus J, Grob P. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002;11:233-238 (Pubitemid 35265252)
27. Shah RK, Kentala E, Healy GB, Roberson DW. Classification and consequences of errors in otolaryngology. Laryngoscope. 2004;114:1322-1335
28. Tongue JR, Epps HR, Forese LL. Communication skills for patient-centered care. Research-based, easily learned techniques for medical interviews that benefit orthopaedic surgeons and their patients. J Bone Joint Surg Am. 2005;87:652-658
29. Boyle D, Dwinnell B, Platt F. Invite, listen, and summarize: a patient-centered communication technique. Acad Med. 2005;80:29-32. (Pubitemid 40075732)
30. Eisenberg JM. Continuing education meets the learning organization: the challenge of a systems approach to patient safety. J Contin Educ Health Prof. 2000;20:197-207.
31. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of Crew Resource Management training in commercial aviation. Document ID 20040089231. NASA Technical Reports Server. Hanover, MD: National Aeronautics and Space Administration; 1999.
32. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. Document ID 20040141631. NASA Technical Reports Server. Hanover, MD: National Aeronautics and Space Administration; 2000.
33. Brooks RL. HRST training: the next step in patient safety? 2008 Feb. http://www.aaos.org/news/aaosnow/feb08/research5.asp. Accessed 2008 Dec 12.
34. World Health Organization World Alliance for Patient Safety. "Clean care is safer care": the first global patient safety challenge. http://www.who.int/gpsc/en/. Accessed 2008 Jun 28.
35. Chassin MR. Is health care ready for six sigma quality? Milbank Q. 1998;76:565-591
36. American Academy of Orthopaedic Surgeons and the Institute for Health Care Communication. Communication skills mentoring program. http://www3.aaos. org/education/csmp/index.cfm. Accessed 2009 Feb 15.
37. Agency for Healthcare Research and Quality (AHRQ). Medical team training using crew resource management principles enhances provider communication and stimulates improvements in patient care. 2008 Apr 14. http://www.innovations. ahrq.gov/content.aspx?id=1809. Accessed 2009 Feb 15.