Skip to main content
SpringerLink
Log in

Prospective collection of error data in orthopaedic and trauma surgery procedures

  • Original Paper
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

The frequency, type and consequences of errors in orthopaedic and trauma surgery procedures should be analysed.

Methods

In a level II trauma centre, errors and intraoperative complications were prospectively recorded concerning type, severity, preventability and consequences. The error-related time delay was also noted.

Results

In 2012, 984 operative cases could be evaluated over six months: 744 elective and 240 emergency procedures. A total 107 errors (10.8 %) in 72 procedures were recorded. There were 78 nonmedical/organisational, nine medical and 20 combined errors. Clinical consequences were seen in 1 % of errors. The error rate was higher in emergency procedures. Time delays were involved in two thirds of the errors (on average 8.5 minutes).

Conclusion

Typical patient- and procedure-related errors can be detected by consequent documentation and analysis. It may help to develop sufficient strategies of error prevention. Because of the often-seen time delay, error prevention may help save time and costs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Rieser S (2011) Statistics of errors in treatment. The appraiser consider a quarter of the claims as justified. Dt Ärztebl 108:A1459 (in German).

  2. Kwaan MR, Studdert DM, Zinner MJ et al (2006) Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 141:353–358

    Article  PubMed  Google Scholar 

  3. Meinberg EG, Stern PJ (2003) Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg 85:193–197

    PubMed  Google Scholar 

  4. Schrappe M, Lessing LC, Albers B et al. (2007) Patients safety 2007. Coalition of Patients safety, Agenda Patientensicherheit (in German).

  5. Ebbeke P (2007) Retained foreign bodies from the view of the OR nurse. Chirurg 78:13–21 (in German)

    Article  PubMed  CAS  Google Scholar 

  6. Jhawar BS, Mitsis D, Duggal N (2007) Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine 7:467–472

    Article  PubMed  Google Scholar 

  7. Wong DA, Herndon JH, Canale ST et al (2009) Medical Errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg 91:547–557

    Article  PubMed  Google Scholar 

  8. Bernstein M, Hebert PC, Etchells E (2003) Patient safety in neurosurgery: detection of errors, prevention of errors, and disclosure of errors. Neurosurg Q 13:125–137

    Article  Google Scholar 

  9. Boström J, Yacoub A, Schramm J (2010) Prospective collection and analysis of error data in a neurosurgical clinic. Clin Neurol Neurosurg 112:314–319

    Article  PubMed  Google Scholar 

  10. Reason JT (2000) Human error: models and management. B M J 320:768–770

    Article  CAS  Google Scholar 

  11. Clarke JR, Johnston J, Finley ED (2007) Getting surgery right. Ann Surg 246:395–405

    Article  PubMed  PubMed Central  Google Scholar 

  12. Nuland SB (2004) Mistakes in the operating room - error and responsibility. N Engl J Med 351:1281–1283

    Article  PubMed  CAS  Google Scholar 

  13. Sexton JB, Thomas EJ, Heimreich RL (2000) Error, stress and teamwork in medicine and aviation: cross sectional surveys. B M J 320:745–749

    Article  CAS  Google Scholar 

  14. Schwartz D, Fischhoff B, Krishnamurti T et al (2013) The Hawthorne effect and emergency awareness. Proc Natl Acad Sci USA 110:15242–15246

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  15. Gawande AA, Studdert DM, Orav EJ et al (2003) Risk factors for retained instruments and sponges after surgery. N Engl J Med 348:229–235

    Article  PubMed  Google Scholar 

  16. Haynes AB, Weiser TG, Berry WR et al (2009) A surgery safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491–499

    Article  PubMed  CAS  Google Scholar 

  17. Panesar SS, Noble DJ, Mirza SB et al (2011) Can the surgical checklist reduce the risk of wrong site surgery in orthopedics? Can the checklist help? Supporting evidence from analysis of a national patient incident reporting system. J Orthop Surg Res 6:18–23

    Article  PubMed  PubMed Central  Google Scholar 

  18. Sewell M, Adebibe M, Jayakumar P et al (2011) Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop 35:897–890

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lessing C (2012) Postoperative counting controls are not standardized. Dt Ärztebl 109:A372-A373 (in German).

  20. Egorova NN, Moskowitz A, Gelijns A et al (2008) Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg 247:13–18

    Article  PubMed  Google Scholar 

  21. Rateau F, Levrant L, Colombel AL et al (2011) Checklist “Patient Safety” in the operating room: one year experience of 40,000 surgical procedures at the university hospital of Nice. Ann Fr Anesth Reanim 30:479–483

    Article  PubMed  CAS  Google Scholar 

  22. Conley DM, Singer SJ, Edmonson L et al (2011) Effective surgical checklist implementation. Am J Coll Surg 212:873–879

    Article  Google Scholar 

  23. Ruchlin HS, Dubbs NL, Callahan MA (2004) The role of leadership in instilling a culture of safety: lessons from the literature. J Healthc Manag 49:47–57

    PubMed  Google Scholar 

  24. Wong J, Khu KJ, Kaderali Z et al (2010) Delays in the operating room: signs of an imperfect system. Can J Surg 53:189–195

    PubMed  PubMed Central  Google Scholar 

  25. Macario A (2010) What does one minute of operating room time cost? J Clin Anesth 22:233–236

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Surgery II: Trauma, Hand, and Reconstructive Surgery, Verbundkranhenhause Bernkastel-Wittlich, Wittlich, Germany

    Reiner Wirbel & Ahmad Yacoub

  2. Anesthesiology Intensive Care and Pain Therapy, Verbundkrankenhause Bernkastel-Wiitlich, Wittlich, Germany

    Marius Dehne

Authors
  1. Reiner Wirbel
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmad Yacoub
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marius Dehne
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Reiner Wirbel.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wirbel, R., Yacoub, A. & Dehne, M. Prospective collection of error data in orthopaedic and trauma surgery procedures. International Orthopaedics (SICOT) 38, 2369–2375 (2014). https://doi.org/10.1007/s00264-014-2438-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-014-2438-3

Keywords

Search

Navigation