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Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 1-2

Best practices in orthopedics

Department of Orthopaedics, IGIMS, Patna, Bihar, India

Date of Submission02-Mar-2022
Date of Decision09-Mar-2022
Date of Acceptance10-Mar-2022
Date of Web Publication15-Mar-2022

Correspondence Address:
Ritesh Runu
Department of Orthopaedics, IGIMS, Patna, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_20_22

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How to cite this article:
Runu R. Best practices in orthopedics. J Orthop Dis Traumatol 2022;5:1-2

How to cite this URL:
Runu R. Best practices in orthopedics. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Jun 6];5:1-2. Available from: https://jodt.org/text.asp?2022/5/1/1/339675

Orthopedic practice, similar to other branches of medicine, is an amalgamation of knowledge, skill, and technology. It is governed by the prime aim of patient safety. However, the safety is compromised in many instances during the course of patient care leading to direct or indirect harm. This was highlighted in 2000 by Kohn et al. in their book titled “To Err is Human: Building a Safer Health System.”[1] In a report from the Institute of Medicine, USA, the number of patient death due to medical errors was found to be more than road traffic accidents, breast cancer, and AIDS in the USA.[2]

In health care, an error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).[3] An adverse event is caused by medical error rather than the underlying condition of the patient.[4] Some of the adverse events are preventable where the care provided failed to meet the standard of care reasonably expected of an average physician qualified to take care of the patient in question.[5] These are considered negligence on the part of the physician for which legal actions can be taken. In hospitals, intensive care units, operating rooms (ORs), and emergency departments (EDs) are zones for high medical errors.

According to Leap et al., errors can occur in diagnosis, during treatment, in prevention, etc.[5] The errors in diagnostics can be due to delay in diagnosis, failure to employ indicated tests, use of outmoded tests or therapy, and failure to act on results of monitoring or testing. During treatment, the error can happen in the performance of an operation, procedure, or test. Error in administering the treatment can be wrong dose or method of using a drug, avoidable delay in treatment, or in responding to an abnormal test. The error in prevention can be the failure to provide prophylactic treatment, inadequate monitoring, or follow-up. Miscellaneous causes of errors may be the failure of communication, equipment failure, system failure, etc.[6] The potential sources of errors can be in the Design, Equipment, Procedures, Operators, Supplies and Materials, and Environment framework.[7]

To increase awareness and reduce patient harm, the American Academy of Orthopaedic Surgeons started a “Sign your site” program in 1997.[6] It focused on reducing the wrong site surgery. Similarly, in 2004, The Joint Commission introduced the Universal Protocol (UP).[8] This was for creating awareness about perioperative surgical safety processes. The processes are in three stages. First is sign in – where the patient identity, procedure, and site of operation are identified. Relevant documentation, diagnostic test results, and requirement of blood products, implants, devices, and any special instruments needed are ascertained.

Second – Mark the site. The anesthetists mark the site of spinal anesthesia or other as required. The surgeon marks the surgical site. This is essential to prevent the wrong site operation. During the time-out, the immediate members of the surgery team, the anesthesia team, the circulating nurse, and OR technician interact actively. The team finally ensures the correct patient, correct site of operation, and correct procedure. Later in 2007, WHO introduced the Safe Surgery Saves Lives Program.[9] The expert team of WHO identified four areas for action – surgical site infection prevention, safe anesthesia, safe surgical teams, and measurement of surgical services. This involved preoperative patient evaluation, surgical intervention, and preparation for appropriate postoperative care. They expanded the measures suggested in UP [Table 1].[9]
Table 1: Surgical safety measures

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To improve the patient safety, creating a safe environment is essential. It means the reduction of risks in the process. To improve the process safety, the establishment of operational systems and processes for reliable patient care is essential.

Kuo and Robb identified six important surgical safety program elements needed to eliminate preventable surgical harm: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. This was concluded on the basis of 36 articles' review.[10]

Standardization of processes in medical care can reduce errors and create a safe environment. It represents an effort to eliminate unnecessary complexity in processes. Some authors feel that standardization in health care may cause a loss of excellence in critical thinking, innovation, learning, flexibility, humanity, and joy in work.[11] But contrary to this, the protocol-based working provides the basic framework for the processes. It defines the steps, reduces unnecessary steps, enhances expertise, and reduces errors. Standardized clinical pathways can make the quality of care more measurable and reproducible. It will support more consistent and reliable treatment decisions.[12]

  References Top

Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.  Back to cited text no. 1
Centers for Disease Control and Prevention (National Center for Health Statistics). Births and deaths: Preliminary data for 1998. Natl Vital Stat Rep 1999;47:6.  Back to cited text no. 2
James R. Human Error. Cambridge, MA: Cambridge University Press; 1990.  Back to cited text no. 3
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.  Back to cited text no. 4
Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. QRB Qual Rev Bull 1993;19:144-9.  Back to cited text no. 5
Canale ST. Wrong-site surgery: A preventable complication. Clin Orthop Relat Res 2005;433:26-9.  Back to cited text no. 6
Perrow C. Normal Accidents. New York: Basic Books; 1984.  Back to cited text no. 7
The Universal Protocol. National Patient Safety Goals. The Joint Commission. Available from: http://www.jointcommission.org. [Last accessed on 2022 Feb 23].  Back to cited text no. 8
World Health Organisation and WHO Patient Safety (2008). The Second Patient Safety Challenge: Safe Surgery Saves Lives. World health Organisation. Available from: https://apps.who.int/iris/handle/10665/70080. [Last accessed on 2022 Feb 12].  Back to cited text no. 9
Kuo CC, Robb WJ 3rd. Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety. Clin Orthop Relat Res 2013;471:1792-800.  Back to cited text no. 10
Goitein L, James B. Standardized best practices and individual craft-based medicine: A conversation about quality. JAMA Intern Med 2016;176:835-8.  Back to cited text no. 11
Graban M, editors. Standardized work as a foundation of lean. In: Lean Hospitals. 3rd ed. Boca Raton, Florida, USA: CRC Press; 2016. p. 93-120.  Back to cited text no. 12


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