But for the AAOS, patient safety certainly is not a new concept. It started more than a decade ago with the issue of wrong-site surgery. The AAOS, working independently, heard about a program brought from England to Canada (1994–1996) that was designed to stop wrong-site surgery. In 1997, the AAOS formed a work group to investigate and report on the program to the AAOS leadership. The result was the “Sign Your Site” program.


Published 3/1/2011

Patient safety is no accident

March 6–12 has been designated Patient Safety Awareness Week. This is the ninth year that this effort has been led by the National Patient Safety Foundation in its continuing efforts to improve patient safety.

In the field of medicine, patient safety—especially patient safety awareness—is a relatively new concern. For years, medical research concentrated only on patient outcomes, the results of medical and surgical interventions.

S. Terry Canale, MD

Over the next year and a half, the AAOS spent $160,000 promoting the “Sign Your Site” program. Surveys at that time found that although 90 percent of AAOS members were aware of the program, only 40 percent actually signed the site. We realized that informing individuals is one thing, but getting them to change their habits is another: Patient safety is no accident.

In December 1999, the Institute of Medicine (IOM) released its report on medical errors, “To Err is Human: Building a Safer Healthcare System.” Statistics in that report caught the attention of both the public and legislators and resulted in the introduction of several bills on patient safety.

Organized medicine went scurrying around to find model patient safety programs and latched on to the Academy’s “Sign Your Site” program. The AAOS program became the darling of all of organized medicine and was adopted as a model for patient safety programs.

Thus it was that the AAOS became a leader in patient safety, ultimately partnering with The Joint Commission in developing the Universal Protocol, with its requirements to sign the surgical site and take a “time-out” to verify the patient’s identity, the exact procedure, and whatever needed to be checked. Today, the Universal Protocol is mandatory for all surgeries.

(By the way, did you know that the time out was originally called the “huddle” because so many AAOS members on the task force were former football players?)

As a result, the AAOS received recognition and, in my mind, was propelled into the leadership role it holds today in organized medicine.

Because of this early success, the AAOS realized the need for patient safety and patient safety programs. In 2003, AAOS President James H. Herndon, MD, dedicated his presidency and his presidential address at the 70th Annual Meeting to the pressing need for patient safety. Dr. Herndon has maintained his commitment to patient safety and just recently participated in a roundtable on the topic (See “What progress in patient safety?” AAOS Now, December 2010).

The Academy’s Patient Safety Committee was formed and charged with monitoring issues, educating the fellowship, and developing plans related to patient safety. The Communication Council, then chaired by Stuart Hirsch, MD, and the Academy’s public relations department, under the direction of Sandy Gordon, developed an award-winning public service advertising (PSA) campaign, “Take Care—Patient Safety is No Accident,” supported by radio and television spots; posters, postcards, and other materials for patients and the public; a Web site about patient safety; and an orthopaedic coalition about patient safety.

Patient safety is “young” relative to the history of medicine, but, as you can see, the AAOS was there at the start, advocated for patient safety, and has remained involved in keeping the patient safety movement alive.

The strength of this commitment was confirmed by the 21 paper and poster presentations dealing with patient safety—and the Patient Safety Booth—at the 2011 Annual Meeting in February. The largest number of papers concerned infections in total joint replacement surgeries. Topics ranged from how to define a surgical wound infection to how to identify and classify periprosthetic infections. New technologies, such as multiplex polymerase chain reaction, measurement of C-reactive protein in synovial fluid rather than in blood serum, and the use of biomarker immunoassays, were covered.

Several presentations described preoperative screening and disinfecting procedures for reducing the risk of surgical site infections, and two suggested postoperative measures—intrawound vancomycin powder and diluted betadine lavage—to prevent infection. Perioperative factors related to the frequency of surgical complications included breaches of “operating room etiquette” and the use of the World Health Organization’s surgical safety checklist.

Finally, a number of risk factors for postoperative infection were identified, including the use of steroids, a previous total joint replacement, obesity, rheumatologic disease, diabetes, coagulopathy, and anemia.

The Academy and AAOS Now applaud Patient Safety Awareness Week. I believe, as you have just seen, that orthopaedists and the AAOS have done—and continue to do—their part, but changing people’s behavior and habits is difficult: Patient safety is no accident.