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Learning from Mistakes

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Quality Improvement and Patient Safety in Orthopaedic Surgery

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Abstract

Surgeons work in complex systems where mistakes are made. Our goals are to reduce and avoid mistakes by learning from those mistakes and preventing patient harm.

We learn as individuals and in groups through both formal and informal observations and discussions. Opportunities for learning from mistakes are discussed such as simulations, virtual reality, video, morbidity and mortality conferences, incident reporting, chart reviews, patient claims and complaints, and prospective risk analyses. Active participation in learning opportunities leads to more retention and transfer of those learnings to future action.

Orthopedic surgeons as leaders and educators, and organizations, can model learning from mistakes by proactive learning efforts, humble thoughtful evaluation when mistakes occur, and subsequent action items.

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Author information

Authors and Affiliations

  1. Retired, Department of Orthopaedic Surgery, Abbott-Northwestern Hospital, Allina Health, Minneapolis, MN, USA

    Peggy L. Naas

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  1. Peggy L. Naas
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Editor information

Editors and Affiliations

  1. Department of Orthopedics, Nationwide Children’s Hospital, Columbus, OH, USA

    Julie Balch Samora

  2. Department of Orthopedics, Stanford University, Stanford, CA, USA

    Kevin G. Shea

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Naas, P.L. (2022). Learning from Mistakes. In: Samora, J.B., Shea, K.G. (eds) Quality Improvement and Patient Safety in Orthopaedic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-031-07105-8_9

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  • DOI: https://doi.org/10.1007/978-3-031-07105-8_9

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-07104-1

  • Online ISBN: 978-3-031-07105-8

  • eBook Packages: MedicineMedicine (R0)

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