Medical errors in orthopaedics. Results of an AAOS member survey.

David A. Wong; James H. Herndon; Terry Canale; Robert L. Brooks; Thomas R. Hunt; Howard R. Epps; Steven S. Fountain; Stephen A. Albanese; Norman A. Johanson

Study

Medical errors in orthopaedics. Results of an AAOS member survey.

March 18, 2009

Wong DA, Herndon JH, Canale T, et al. J Bone Joint Surg Am. 2009;91(3):547-57.

View more articles from the same authors.

The majority of practicing orthopedic surgeons in this study had witnessed a medical error within the prior 6 months, with medication errors and wrong-site surgery the most serious problems reported.

PubMed citation

Available at

Related Resources From the Same Author(s)

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

June 24, 2009

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

November 17, 2010

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

December 3, 2014

Simulation study of rested versus sleep-deprived anesthesiologists.

January 9, 2005

Patient safety climate among orthopaedic surgery residents.

July 6, 2011

The business case for patient safety.

February 14, 2007

Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey.

February 20, 2008

A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds.

April 8, 2009

Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.

January 10, 2007

Older patients' perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries.

September 24, 2008

Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis.

June 26, 2013

Post-implementation optimization of medication alerts in hospital computerized provider order entry systems: a scoping review.

December 6, 2023

Stepping out further from the shadows: disclosure of harmful radiologic errors to patients.

February 15, 2012

Preventable deaths: who, how often, and why?

March 27, 2005

Fatigue among clinicians and the safety of patients.

March 6, 2005

Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.

August 8, 2018

How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.

September 28, 2011

Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping.

April 30, 2008

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review.

November 15, 2006

The development and implementation of checklists in obstetrics.

September 27, 2017

Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns using a new observation system.

July 30, 2008

Spinal surgery and patient safety: a systems approach.

May 10, 2006

Medication reconciliation in ambulatory care: attempts at improvement.

October 28, 2009

Cause and effect analysis of closed claims in obstetrics and gynecology.

May 18, 2005

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and intervention.

April 1, 2009

Using the rapid response system to provide better oversight of patient care processes.

November 14, 2007

Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.

September 4, 2019

Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents.

June 6, 2012

Using computerized virtual cases to explore diagnostic error in practicing physicians.

February 13, 2019

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

August 30, 2017

Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.

November 19, 2014

Using a quantitative risk register to promote learning from a patient safety reporting system.

February 4, 2015

Risk of adverse drug events by patient destination after hospital discharge.

September 21, 2005

Active surveillance of vaccine safety: a system to detect early signs of adverse events.

May 4, 2005

Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.

August 9, 2006

Power of saying ‘I Don’t Know’: psychological safety and participatory strategies for healthcare leaders.

March 13, 2024

Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire—Ambulatory Version.

March 21, 2007

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

March 16, 2011

Patient safety and quality improvement adaptation during the COVID-19 pandemic.

April 21, 2021

Causes of preventable drug-related hospital admissions: a qualitative study.

April 23, 2008

A system analysis of a suboptimal surgical experience.

February 4, 2009

Individual surgeon mortality rates: can outliers be detected? A national utility analysis.

November 16, 2016

Identifying cross contaminants and specimen mix-ups in surgical pathology.

July 23, 2008

Emergency department medication lists are not accurate.

November 12, 2008

"To err is human" but disclosure must be taught: a simulation-based assessment study.

February 28, 2018

To err is human: quality and safety issues in spine care.

May 30, 2007

Understanding diagnostic errors in medicine: a lesson from aviation.

June 21, 2006

Clinical perspective: creating an effective practice peer review process—a primer.

March 29, 2017

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

August 4, 2010

The next organizational challenge: finding and addressing diagnostic error.

March 5, 2014

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

July 16, 2014

Use of a surgical safety checklist to improve team communication.

September 21, 2016

The cost of disruptive and unprofessional behaviors in health care.

October 16, 2013

A check-up for safety culture in "my patient care area."

November 14, 2007

Safe use of electronic health records and health information technology systems: trust but verify.

December 18, 2013

Three Australian whistleblowing sagas: lessons for internal and external regulation.

March 6, 2005

A middle ground on public accountability.

March 6, 2005

Development of a trigger tool to identify adverse events and harm in emergency medical services.

September 20, 2017

A safety culture transformation: its effects at a children's hospital.

September 12, 2012

Use of an emergency manual during an intraoperative cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool.

August 15, 2018

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

January 21, 2009

Diagnostic error and clinical reasoning.

January 13, 2010

Prescribers' responses to alerts during medication ordering in the long term care setting.

August 30, 2006

The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation.

May 31, 2006

Direct oral anticoagulants: a review of common medication errors.

November 21, 2018

Educational interventions to reduce prescribing errors.

May 7, 2008

Nurse reports of adverse events during sedation procedures at a pediatric hospital.

November 11, 2009

Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests.

October 14, 2009

Health literacy, medication errors, and health outcomes: is there a relationship?

July 5, 2006

Impact of the nurse shortage on hospital patient care: comparative perspectives.

July 25, 2007

Health plan members' views about disclosure of medical errors.

March 6, 2005

Rural inpatient telepharmacy consultation demonstration for after-hours medication review.

October 3, 2012

A leadership framework for culture change in health care.

July 19, 2006

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.

June 20, 2007

The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better.

April 27, 2011

Managing cognitive biases during disaster response: the development of an aide memoire.

May 20, 2020

Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health Committee.

June 15, 2016

Crisis checklists for the operating room: development and pilot testing.

January 30, 2005

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

January 25, 2012

The economics of health care quality and medical errors.

November 14, 2012

Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.

August 30, 2017

Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

January 18, 2006

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

October 26, 2005

Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

January 11, 2012

Impact of electronic prescribing in a hospital setting: a process-focused evaluation.

August 27, 2008

When a vital sign leads a country astray—the opioid epidemic.

September 4, 2019

Disclosing harmful mammography errors to patients.

December 16, 2009

Extent of diagnostic agreement among medical referrals.

April 12, 2017

Incidence and types of adverse events and negligent care in Utah and Colorado.

March 27, 2005

The SAGES FUSE program: bridging a patient safety gap.

October 22, 2014

Missed opportunities in the primary care management of early acute ischemic heart disease.

November 29, 2006

Operating room fires.

February 6, 2019

Reducing warfarin medication interactions: an interrupted time series evaluation.

June 14, 2006

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.

April 13, 2016

Real-time automated paging and decision support for critical laboratory abnormalities.

August 17, 2011

The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.

April 19, 2006

Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems.

March 8, 2006

Establishing a simulation center for surgical skills: what to do and how to do it.

September 12, 2007

Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases.

November 22, 2017

Related Resources

WebM&M Cases

A Double “Never Event”: Wrong Patient and Wrong Side.

September 27, 2023

Factors contributing to preventing operating room "never events": a machine learning analysis.

May 10, 2023

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

February 8, 2023

Trial and error: learning from malpractice claims in childhood surgery.

August 24, 2022

High-reliability organisation principles implemented in dentistry.

July 27, 2022

Implicit racial bias in pediatric orthopaedic surgery.

June 15, 2022

Clinically significant medication errors in surgical units detected by clinical pharmacist: a real-life study.

November 10, 2021

Common general surgical never events: analysis of NHS England never event data.

April 7, 2021

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

Health information technology-related wrong-patient errors: context is critical.

January 27, 2021

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

January 20, 2021

WebM&M Cases

Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia

July 29, 2020

Using Safety-II and resilient healthcare principles to learn from Never Events.

April 8, 2020

Pain Alleviation Toolkit.

April 8, 2020

Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system.

December 18, 2019

Patient Safety Primers

Never Events

September 7, 2019

WebM&M Cases

If You Say So: Taking a Syringe at Face Value in the Operating Room

June 1, 2019

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Association of opioid-related adverse drug events with clinical and cost outcomes among surgical patients in a large integrated health care delivery system.

June 20, 2018

High reliability of care in orthopedic surgery: are we there yet?

November 16, 2016

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

February 3, 2016

Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.

March 25, 2015

Wrong-side thoracentesis: lessons learned from root cause analysis.

July 2, 2014

"It is the left eye, right?"

June 11, 2014

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

March 26, 2014

Using "near misses" analysis to prevent wrong-site surgery.

October 30, 2013

Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors.

May 8, 2013

Priority patient safety issues identified by perioperative nurses.

May 8, 2013

Surgical never events in the United States.

January 9, 2013

Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery.

December 5, 2012

See More About The Topic

Operating Room

Risk Managers

Quality and Safety Professionals

Orthopedic Surgery

Medication Errors/Preventable Adverse Drug Events

Medical errors in orthopaedics. Results of an AAOS member survey.

Never Events

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Medical errors in orthopaedics. Results of an AAOS member survey.

Never Events

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site