Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors

Figures & data

Table 1 2 × 2 table to calculate degree of association

	Harm	No harm	Total
Category A	a	b	a + b
All categories – category A	c	d	c + d
Total	a + c	b + d	a + b + c + d

Notes: Or = Odds of harm in orthopedic category A/Odds of harm across all orthopedic categories; Or = (a/b)/(c/d).

Abbreviation: Or, odds ratio.

Table 2 Frequency of harm by category

Category	No harm (n)	Low harm	Moderate harm	Severe harm	Death	All harm (n)	Example
Implementation of care and ongoing monitoring/review	1194	1935	600	52	13	2600	“Admitted 28/08/05 with fracture right NOF, very frail. In atrial fibrillation but not confused. No input requested from medical team. Starved for op 30/08/05 and 31/08/05. Postponed due to raised INR. Starved again 01/09/05. Anaesthetist promised to take her although very high risk, theatre postponed again at 16.00.”
Self-harming behavior	52	34	11	3	0	48	“Pt checked at approx 00.00 hrs and appeared settled. Pt checked again around 01.00 hrs and found lying straight on back with upper body twisted over to right hand side face facing floor. I [SN (1)] shouted the pt name and no response – turned on the light and called for help. I noticed blood on the floor and when other Staff Nurse arrived I noticed a cord around pt neck attached to unit on wall. SHO (2) arrived immediately and crash team were called. Pt’s head was being supported by SHO (2) and cord cut by myself and SN (3). Pt put onto back (face very blue and blood around nose). CPR was commenced with team present – this was unfortunately unsuccessful”
Infection control incident	576	244	192	17	15	468	“30.08.06 – Admitted with fractured NOF, unfit for surgery 31.08.06. 30.09.06 – MRSA screen completed – confirmed neg 04.09.06. 01.09.06 – OP – 13.09 Swab taken – leakage from wound. 15.09.06 Wound dry and healed – sutures removed. 18.09.06 Confirmed MRSA from wound swab result. 19.09.06 Reviewed by Dr – nil ordered, wound healed 20.09.06 – wound discharging. 21.09.06 Urine output decreased, wound leaking blood cultures taken. 23.09.06 Blood cultures confirmed MRSA bacteraemia. 27.09.06 Pt deceased – cause of death recorded as renal 2nd to MRSA sepsis.”
Other	603	304	69	9	10	392	“On turning patient it was noted the sacrum and buttocks red, small break in skin. Grade 2 pressure sore.”
Treatment, procedure	3695	3695	1548	489	38	2091	“Patient undergoing cemented hemiarthroplasty under spinal anaesthetic. Shortly after cementing the patient deteriorated dramatically leading to a cardiac arrest from which patient failed to recover despite cardio pulmonary resuscitation. Patient certified dead at 10:55 on 01.06.09.”
Patient accident	12,858	4969	611	55	4	5639	“Pt found on floor, hoisted back to bed, dressed skin tear on R lower leg, SHO reviewed, xray L hip – periprosthetic # hip – site informed.”
Disruptive, aggressive behavior (includes patient-to-patient)	117	43	3	0	0	46	“G has been restless and trying to climb out of bed all night. DID NOT FALL. At 02:30 approx noticed that her bed sheets were covered in blood. Leg examined and sheets changed but no obvious cause for bleeding observed although the inside of the plaster soaked in blood. Dr S informed and visited.”
Clinical assessment (including diagnosis, scans, tests, assessments)	1053	267	107	16	4	394	“Received request card from B2 requesting pelvis x-rays on a [Patient name] dob [DOB]. This pt was brought from the ward by a porter. This pt was identified and upon further questioning it was discovered that this pt had not had any problems with her hip or any operations on her hip and was in hospital with a fractured shoulder. She did however point out that there was another pt on B2 with the surname who was awaiting hip surgery. Contacted requesting Dr who stated he had put the wrong name sticker on request card. [Patient name] was returned to ward and a new request card was written.”
Medical device/equipment	1231	357	64	0	2	423	“Pt was sent for as her anaesthetic commenced. S/N and ODS went to check the Birmingham Resurfacing prosthesis and a 50 mm head and 56 mm cup × 2 were found to be missing. I had arranged that all prosthesis should be on a before 9 am delivery due to the current level of activity. Pt anaesthetic was stopped whilst the prosthesis was sourced. The company was contacted and the prosthesis had been despatched on Friday – but they were unable to ascertain where it was. The hospital at X was contacted and they were able to supply us. A taxi was despatched. Pt was sent to recovery and rescheduled for when the prosthesis had arrived. On contacting supplies and the company the order was ordered on and before 9 am on 31st June.”
Patient abuse (by staff/third party)	59	16		0	0	17	“Whilst accompanying consultant in his ward round, staff member found his manner towards patient was inappropriate – saying the following: You should not have come into this hospital there nothing wrong with you. There are more patients who need your bed more than you do. Consultant then proceeded to the husband saying the same things he said to his wife and they had a heated discussion. Approached deputy sister whose in charge that time, and complaint procedure was given. Patient in Bed 2 heard what consultant had told patient and is willing to be a witness.”
Access, admission, transfer, discharge (including missing patient)	2196	479	118	5	4	606	“Handover taken from A+E staff at around 1630, Handover stated fractured Neck of femur and history of COPD, on home oxygen 2 litres. I contacted A+E minors at 1930 as patient still not transfered, and I was wondering if she was still coming to the ward, or if her condition had changed and she was going elsewhere. I was told she was fine, and the delay was just due to shortage of porters. Patient arrived on the ward at about 2000 escorted by staff nurse, transfered onto bed by colleagues (support workers and student nurse) as I was trying to order some bloods for another patient on the computer. The A+E nurse came to the office to ask if I had recieved a handover, I said I had recieved one at 1630 and asked had her condition changed, he said it had not. As soon as he left the ward, my student nurse came to get me to see the patient as she was concerned. The patient was in respiratory distress, she was struggling to breathe, gasping for air through her mouth, her respiratory rate was 30, her oxygen saturations were 79%, she was tachycardic 105 and her BP was elevated from previously. EWS was 4. HO immediately called and changed her nasal specs to a facemask. The patient was also in severe pain and had not had any analgesia since 1830 in A+E. Sevredol prescribed and given, blood gases taken, chest x-ray taken, nebuliser given, SHO called for further advice. The patient complained of abdominal pain, and was found to be in urinary retention, she said she had not passed urine since the morning, and had talked to staff in A+E about it. Catheterzed and drained 600 mls straight away.”
Medication	3617	579	149	15		744	“Patient admitted with humeral # following fall 10/1/08. ORIF 11/1/08 and revision surgery 18/1/08 Patient prescribed Diclofenac 50 mg tds on admission continued for next 14 days, no Gl ulcer prophylaxis given and patient starved for several periods of time. 24/1/08 patient had major upper Gl bleed, required laparotomy for oversew bleeding DU, massive transfusion and ICU admission. No evidence that NSAID prescription reviewed or GI ulcer prophylaxis considered at any stage before GI bleed despite patient being in high risk group for NSAID induced Gl bleeding.”
Consent, communication, confidentiality	1462	215	59	4	1	279	“CT scan of pt left humerus was booked in standard manner using EPR system whilst she was inpatient on Cambridge ward. The request stated she had a pathalogical fracture of her left humerus. The CT took place on 25th April at 9.30 am. When the films were reviewed that afternoon it was clear that infact the wrong patient had been scanned. The radiology department were informed of this error via. Unfortunately we are unable to find out who in fact did receive the CT scan of her humerus as there is no way of identifying the person from the images and clearly there was no clinical indication for her to receive this scan. Asking CT to perform the scan on the correct patient so that surgery can be planned, I was informed to submit a new for on EPR.”
Infrastructure (including staffing, facilities, environment)	2370	370	66	4	1	441	“Patient waited more than 48 hours for surgery, unfit 11 days. Diagnosis # NOF.”
Documentation (including electronic and paper records, identification and drug charts)	2530	240	52	2	0	294	“Pt attended clinic for review post-op total knee replacement. Operation note was absent from her medical notes.”
Total	33,613					14,482

Table 3 Proportion of harmful incidents in each category

Category	All harm	Percentage of all patient safety incidents (n = 48,095)
Patient accident	5639	11.72
Implementation of care and ongoing monitoring/review	2600	5.41
Treatment, procedure	2091	4.35
Medication	744	1.55
Access, admission, transfer, discharge (including missing patient)	606	1.26
Infection control incident	468	0.97
Infrastructure (including staffing, facilities, environment)	441	0.92
Medical device/equipment	423	0.88
Clinical assessment (including diagnosis, scans, tests, assessments)	394	0.82
Other	392	0.82
Documentation (including electronic and paper records, identification, and drug charts)	294	0.61
Consent, communication, confidentiality	279	0.58
Self-harming behavior	48	0.10
Disruptive, aggressive behavior (includes patient-to-patient)	46	0.10
Patient abuse(by staff/third party)	17	0.04
Total	14,482	30.11

Figure 1 Odds ratios of different categories of harm.