Attention to patient safety issues has increased since the Institute of Medicine’s report, “To Err is Human: Building a Safer Health System” in 1999. Major areas of concern include wrong-site surgery, medication errors, healthcare-acquired infections, falls, readmissions, and diagnostic errors.
National Patient Safety Goals, introduced in 2002, were developed to help accredited organizations address specific patient safety issues. These goals have recently been updated to focus on the following areas:
- improving the accuracy of patient identification
- improving the effectiveness of communication among caregivers
- improving the safety of using medications
- reducing the risk of healthcare-associated infections
- reducing the risk of patient harm resulting from falls
- preventing healthcare-associated pressure ulcers
- identifying safety risks inherent in an organization’s patient population
The AAOS Patient Safety Committee is committed to providing AAOS members with the necessary resources to meet the charges outlined in these goals.
Correct patient identification
The orthopaedic environment can often be chaotic—particularly in trauma or emergency situations. As a result, simple, routine tasks may be neglected or overlooked. This can lead to patients receiving the wrong treatment or an incorrect blood transfusion.
Thus, it is imperative for the orthopaedic team to use two patient identifiers, such as name and date of birth. By identifying the correct patient, the team mitigates the risk of other mistakes that can occur during surgery.
Orthopaedic surgeons can help create a culture that welcomes open communication and fosters teamwork. In such an environment, any member of the team can help identify situations in which the patient is at risk, thus making it possible to correct the situation before a catastrophic event occurs. Taking a time-out before a procedure to ensure proper identification of the patient and the correct surgical site is one step. But speaking up and being heard is everyone’s responsibility, not just the surgeon’s.
Safe medication practices
The orthopaedic team is also responsible for ensuring safe medication practices. Because many orthopaedic patients are likely taking several medications—specifically anti-clotting and opioid pain medications—their risk of having an adverse drug event is high. Labeling medications before procedures and taking extra precautions with patients taking blood-thinning drugs can help reduce the risk.
Take advantage of opportunities for cross-collaboration with other healthcare providers such as nurses and pharmacists to ensure patient safety. Adhering to safe medication practices has implications for infection prevention, too.
One of the most common complications during the perioperative and postoperative periods is a surgical site infection (SSI). The National Patient Safety Goals suggest adhering to proven guidelines to prevent difficult-to-treat infections, bloodstream infections associated with central lines, SSIs, and urinary tract infections associated with catheters. Orthopaedic patients are generally at significant risk for each of these infections, making prophylaxis critical.
AAOS members can work with infection control/prevention officers and infectious disease pharmacists to ensure that patients receive the most appropriate antibiotic regimen. Not only will this reduce the incidence of surgical complications, but it will help curb the inappropriate antibiotic use that often leads to antimicrobial resistance, and secondary infections associated with Clostridium difficile.
Resources and future plans
As a leader in the patient safety community, the AAOS Patient Safety Committee maintains relationships with organizations such as the Joint Commission, the World Health Organization, and the Centers for Disease Control and Prevention. Through these relationships, the Patient Safety Committee develops programs and materials to increase safe practices in orthopaedics.
For example, the AAOS has a number of resources to support efforts to reduce medical errors and provide quality care. The AAOS has adopted position statements centered on antibiotic prophylaxis, wrong-site surgeries, and medical error reporting systems. Other resources include information about fall prevention, bacterial decolonization, hand hygiene, communication, and medication safety. These materials are continually updated by the Patient Safety Committee and incorporate the latest evidence-based research on the most effective practices.
This year, the Patient Safety Committee will sponsor the first Patient Safety Summit, Aug. 5–6, in Chicago. The goal of the Summit is to identify common complications associated with high-volume orthopaedic procedures and develop strategies to mitigate the effects of these complications.
The Patient Safety Committee has established a set of charges that include using available data and literature, along with evidence-based tools, to help reduce readmissions and reoperations. Once preventive and interventional strategies are developed, the committee will help champion and disseminate them through education modules adaptable to individual institutions.
Paul Zemaitis is a regulatory/patient safety analyst, biomedical research and regulation, in the AAOS department of research & scientific affairs and the liaison to the AAOS Patient Safety Committee. He can be reached at firstname.lastname@example.org
2012 Academy Row Slide Set (PDF)