Narrow Results Clear All
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Teamwork 1
- Device-related Complications 1
- Identification Errors 2
- Medical Complications 1
- Medication Safety 1
- MRI safety 1
- Surgical Complications 6
Search results for ""
Cases & Commentaries
- Web M&M
Stephanie Rogers, MD, and Derek Ward, MD; April 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
Web Resource > Multi-use Website
Patient Safety Committee. American Academy of Orthopaedic Surgeons.
This Web site includes patient safety-related materials for orthopedic surgeons such as checklists, educational modules, tips, and American Academy of Orthopaedic Surgeons (AAOS) official statements.
Journal Article > Study
Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.
Rampersaud YR, Moro ER, Neary MA, et al. Spine. 2006;31:1503-1510.
The investigators sought to identify the types of adverse events (AE) that can take place during spinal surgery. By assessing the relationship of AEs to complications, they believe their findings will support the development of prevention activities to improve patient safety.
Journal Article > Study
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-415.
Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.
Journal Article > Study
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Bergal LM, Schwarzkopf R, Walsh M, Tejwani NC. J Patient Saf. 2010;6:221-225.
Wrong-site surgeries remain a persistent safety issue, despite extensive efforts by regulatory bodies and professional societies to address the problem. One such intervention, initially adopted by the American Academy of Orthopaedic Surgeons, requires surgeons to sign the site of the surgery by marking the site of the operation on the body. This initiative has been less successful than hoped. In this study, investigators attempted to engage patients in safety by having patients themselves sign the site. Unfortunately, fewer than 70% of patients successfully followed the instructions and successfully marked the incision site. While only a few patients committed an overt error (i.e., signing the wrong site), the suboptimal adherence in this study indicates that site marking protocols may not benefit from increased patient engagement.
Special or Theme Issue
Azar FM, ed. Orthop Clin North Am. 2018;49:A1-A8,389-552.
Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.