Published: 2016-12-14

Patient harm and preventable error in orthopedic surgery

Khaled J. Saleh, Michael T. Ginnetti, Erik C. Curry, Tony H. Tzeng, Mouhanad M El-Othmani


In 1999, the Institute of Medicine released a report estimating that between 44,000 to 98,000 Americans die each year as a result of medical errors. The frequency of these errors has continued to rise, in addition to the significant patient morbidity and mortality, which give rise to a substantial economic burden.  This study used the PubMed database to review the terminology associated with medical errors, the current prevalence of medical errors within orthopaedics, and strategies for prevention.  Patient safety is of the utmost importance. Medical errors still occur and efforts should be focused to standardize care processes, improve error reporting, and promote a team based care process to a reduce harm and promote patient safety.


Preventable harm, Medical error, Orthopaedic surgery, Surgical risks, Patient safety

Full Text:



Brennan TA, Leape LL, Laird NM. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-6.

de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216-23.

To Err Is Human: Building a Safer Health System. The National Academies Press, 2000.

James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-8.

Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff (Millwood). 2011;30(4):596-603.

Meakins JL. Site and side of surgery: getting it right. Can J Surg. 2003;46(2):85-9.

Wong D, Herndon J, Canale T. An AOA critical issue. Medical errors in orthopaedics: practical pointers for prevention. J Bone Joint Surg Am. 2002;84-A(11):2097-100.

Wong DA, Herndon JH, Canale ST. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am. 2009;91(3):547-557.

Reason J. Human Error. Cambridge, MA: Cambridge University Press; 1990.

Grober ED, Bohnen JM. Defining medical error. Can J Surg. 2005;48(1):39-44.

Thomas E, Brennan T. Errors and adverse events in medicine: An overview. In: Vincent C, ed. Clinical Risk Management: Enhancing Patient Safety. London: BMJ Publishing. 2001:31-43.

Conceptual Framework for the International Classification for Patient Safety. World Health Organization; 2009:

Patient Safety: Achieving a New Standard for Care. The National Academies Press, 2004.

Hofer TP, Kerr EA, Hayward RA. What is an error? Eff Clin Pract. 2000;3(6):261-9.

Leape LL, Brennan TA, Laird N. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-84.

Thomas EJ, Studdert DM, Burstin HR. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38(3):261-71.

Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995;163(9):458-71.

O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119(5):370-6.

Anderson O, Davis R, Hanna GB, Vincent CA. Surgical adverse events: a systematic review. Am J Surg. 2013;206(2):253-62.

Wrong-Site Surgery. Accessed 02/20/15.

Stahel PF, Sabel AL, Victoroff MS. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145(10):978-84.

Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003;85-A(2):193-7.

Schweitzer KM, Brimmo O, May R, Parekh SG. Incidence of wrong-site surgery among foot and ankle surgeons. Foot Ankle Spec. 2011;4(1):10-13.

Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004;239(4):475-82.

Leape LL. Error in medicine. JAMA. 1994;272(23):1851-7.

Reason J. Human error: models and management. West J Med. 2000;172(6):393-6.

Cobb TK. Wrong site surgery-where are we and what is the next step? Hand (N Y). 2012;7(2):229-32.

Wu RL, Aufses AH. Characteristics and costs of surgical scheduling errors. Am J Surg. 2012;204(4):468-73.

Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34.

Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-4.

Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614-21.

Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-63.

Singh A, Yian EH, Dillon MT, Takayanagi M, Burke MF, Navarro RA. The effect of surgeon and hospital volume on shoulder arthroplasty perioperative quality metrics. J Shoulder Elbow Surg. 2014;23(8):1187-94.

Lau RL, Perruccio AV, Gandhi R, Mahomed NN. The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature. BMC Musculoskelet Disord. 2012;13:250.

Hammond JW, Queale WS, Kim TK, McFarland EG. Surgeon experience and clinical and economic outcomes for shoulder arthroplasty. J Bone Joint Surg Am. 2003;85-A(12):2318-24.

Darzi A, Mackay S. Assessment of surgical competence. Qual Health Care. 2001;10(Suppl 2):ii64-9.

Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet. 1998;352(9135):1191.

O'Brien MJ, O'Toole RV, Newell MZ. Does sleep deprivation impair orthopaedic surgeons' cognitive and psychomotor performance? J Bone Joint Surg Am. 2012;94(21):1975-81.

McCormick F, Kadzielski J, Landrigan CP, Evans B, Herndon JH, Rubash HE. Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents. Arch Surg. 2012;147(5):430-5.

Ellman PI, Law MG, Tache-Leon C. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg. 2004;78(3):906-11.

Ellman PI, Kron IL, Alvis JS. Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes. Ann Thorac Surg. 2005;80(1):60-4.

Universal Protocol. Accessed 11/10/2014.

Kuo CC, Robb WJ. Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety. Clin Orthop Relat Res. 2013;471(6):1792-800.

Stahel PF, Mehler PS, Clarke TJ, Varnell J. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14.

Logan CA, Cressey BD, Wu RY. Monitoring universal protocol compliance through real-time clandestine observation by medical students results in performance improvement. J Surg Educ. 2012;69(1):41-6.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141(4):353-7.

Vachhani JA, Klopfenstein JD. Incidence of neurosurgical wrong-site surgery before and after implementation of the universal protocol. Neurosurgery. 2013;72(4):590-5.

James MA, Seiler JG, Harrast JJ, Emery SE, Hurwitz S. The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am. 2012;94(1):e2(1-12).

Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. Agency for Healthcare Research and Quality, 2014.

Nawaz H, Edmondson AC, Tzeng TH, Saleh JK, Bozic KJ, Saleh KJ. Teaming: an approach to the growing complexities in health care: AOA critical issues. J Bone Joint Surg Am. 2014;96(21):