title: Identifying error pathways during elbow and knee replacements.
abstract: The aim of our study was to identify errors and error pathways during joint replacements and to propose improvements. A time-action and error analysis method was adapted for use during surgery. The error analysis consisted of identifying all possible errors, determining error paths presented in an error chart, quantifying errors, and determining the impact of errors. This method was used to evaluate joint replacements. We evaluated five knee and 11 elbow replacements done by two experienced surgeons. The main error for elbow replacements was caused by inadequate instruments. The main error for knee replacements was caused by inexperienced nurses being unfamiliar with guiding instruments. The time-action analysis showed a large variation in procedure duration. The main surgical limitations for both procedures were waiting caused by the cementing process and waiting caused by inexperienced scrub nurses. Our study identified errors and surgical limitations during joint replacements by using time-action and error analysis. Placement of both prostheses will benefit from new fixation techniques, a more experienced nursing staff, and more organized instrument tables.
authors.affiliation: Delft University of Technology, Faculty of Design, Engineering and Production, The Netherlands.
authors.forename: Joanne P J
authors.initials: JP
authors.lastname: Minekus
authors.forename: Piet M
authors.initials: PM
authors.lastname: Rozing
authors.forename: Rob
authors.initials: R
authors.lastname: Nelissen
authors.forename: Jenny
authors.initials: J
authors.lastname: Dankelman
mesh_terms: D019643:Arthroplasty, Replacement; D019645:Arthroplasty, Replacement, Knee / Q000379:methods; D002983:Clinical Competence; D004551:Elbow Joint / Q000601:surgery*; D006801:Humans; D007400:Interprofessional Relations; D007431:Intraoperative Complications / Q000209:etiology*; D007432:Intraoperative Period; D019300:Medical Errors; D024802:Nurse's Role; D010819:Physician's Role