Published 8/1/2012
John R. Tongue, MD

Patient Safety Is Our Job #1

Like other physicians, we orthopaedic surgeons quickly learned the dictum attributed to Hippocrates: First, do no harm. But putting this precept into practice takes more than simply repeating it, like a mantra, whenever we approach a patient. And, as our knowledge increases and technology advances, knowing what will “do no harm” becomes more problematic.

During the past 40 years, orthopaedic surgery has often been recognized as the most dynamic field in medicine. We have benefited from a dazzling array of innovative new technologies and scientific knowledge. Pundits have described us as the “rock stars of medicine.” Yet, while employing these powerful new treatments, we may not have recognized opportunities to reduce the severity and frequency of unintended medical errors.

Here is a case in point: Fifteen years ago, in 1997, the Academy adopted an advisory statement on wrong-site surgery and introduced—and widely promoted—the “Sign Your Site” program. That was followed in 1999 by the Institute of Medicine’s report, To Err Is Human: Building a Safer Health System; the introduction of surgical checklists; and, most recently, the World Health Organization’s “Safe Surgery Saves Lives” initiative in 2009.

However, according to The Joint Commission, the number of reported wrong-site surgeries has not been reduced and, in fact, has probably risen. More importantly, across all fields of medicine, thousands of preventable complications occur each day in U.S. hospitals.

We must do better.

Are we the problem?
In 2005, the AAOS Patient Safety Committee surveyed members on observed incidents of medical errors in orthopaedic surgery. More than 1 in 4 incidents reported were due to problems in communication. If communication problems by orthopaedic surgeons represent such a significant source of errors in the treatment of our patients, we must do better.

It’s true that we often work under very stressful and changing environments. And now, with ever more complex treatments and time pressure, we have reached a tipping point. In his book The Checklist Manifesto: How to Get Things Right, Atul Gawande, MD, explains, “In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for.”

We love doing surgery; it’s the most dramatic and satisfying aspect of our daily work. Yet even the greatest surgeon of all time, William Halsted, once wrote, “Surgery is fine, it’s operating that is difficult.”

In the operating room (OR), surrounded by anesthesiologists, nurses, technicians, and other clinicians, the patient is no longer “my” patient; he or she is “our” patient. It is not only “I” who have the responsibility to bring this patient through safely; it is “our” responsibility. “I” may call the shots, but if something goes wrong, “we” spring into action.

The gap between “I” and “we” is more than a matter of numbers. For too long, OR staff have been viewed as subordinate to the surgeon and perceived a “power differential” that blocked communication, often at critical moments. To do better, we must be a team, watching out for the patient and for each other, each willing to speak up—and to listen—when something seems a little off.

The AAOS and patient safety
The first to call attention to the problem of communication and teamwork in ensuring patient safety was James H. Herndon, MD, MBA, who served as AAOS president in 2003. His efforts led to the establishment of our Patient Safety Committee, led this year by William J. Robb III, MD.

This month, the Patient Safety Committee is sponsoring the first AAOS Surgical Safety Summit in Rosemont, Ill. (August 5–6, 2012). Surgical safety is a critical opportunity to improve the care of orthopaedic patients. This summit will introduce enhanced surgical team communication strategies and will focus on the development, implementation, and validation of surgical processes targeted to reduce significant orthopaedic complications. By employing new social science research and renewed energies, we now have an enormous opportunity to improve the art, as well as the science, of orthopaedic surgery. (For more on the summit, see this issue’s cover story on “AAOS Hosts Patient Safety Summit.”)

Recognizing the imperative to work in larger care teams to improve efficiency and safety, your board has recently approved the development and implementation of a new pilot program of team training, using an evidence-based program called Team-STEPPS (Fig. 1). Over the next 3 years, the AAOS will present this program to 80 orthopaedic institutions. John S. Webster, MD, MBA, a master trainer and orthopaedic surgeon, champions this educational initiative.

Teaching orthopaedic teams to communicate skillfully builds on our successful 12-year experience in teaching interpersonal communications through the Academy. The AAOS Communication Skills Mentoring Program (CSMP) is led by Dwight W. Burney III, MD. Our dedicated, highly trained CSMP mentors have already conducted more than 300 workshops, involving more than 5,000 residents and fellows.

From this core group, more than 20 Team-STEPPS trainers have been identified and are ready to begin outreach. This orthopaedic-specific training program will help teams of experts become expert teams, reducing stress and improving care. Second Vice President Frederick M. Azar, MD, chairs the Board Patient Safety and Quality Oversight Work Group to coordinate this important initiative.

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