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

Abstract

BackgroundWith scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS) in England and Wales is an underused resource which collects intelligence from reports about health care error.MethodsUsing methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs) and 95% confidence intervals (CIs).ResultsThe largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%). Of those, 14,482/48,095 (30.1%) resulted in iatrogenic harm to the patient and 71/48,095 (0.15%) resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38); self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18); and infection control (OR 1.91, 95% CI 1.69, 2.17). We analyze these data to quantify the extent and type of iatrogenic harm in the specialty, and make suggestions on the way forward.Conclusion and level of evidenceDespite the limitations of such analyses, it is clear that there are many proven interventions which can improve patient safety and need to be implemented. Avoidable errors must be prevented, lest we be accused of contravening our fundamental duty of primum non nocere. This is a level III evidence-based study.

Safety Incidents in the Primary Care Office Setting

“…29,30 Despite this, reporting to the NRLS has increased in the last decade, providing large quantities of data from which to generate learning. 31,32 There may be other harmful incident types occurring in family practice that are underreported owing to fear of reprimand. 33 However, despite limitations from underreporting and reporting biases, analyses of NRLS data have played an important role in generating lessons to mitigate harmful incidents in other areas of clinical practice.…”

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice

“…159,160 There may be other harmful incident types occurring in primary care that are under-reported because of a fear of being reprimanded. 157 However, despite limitations from under-reporting and reporting biases, analyses of NRLS data have played an important role in generating lessons to mitigate harmful incidents in other areas of clinical practice.…”

A Quality Improvement Initiative: Supporting the Potential of Foundation Year Doctors with a "Trauma Innovation Forum"

“…This involvement also leads to more sustainable quality improvement cultures that can be embedded within organizations [1]. Particularly, key is improvement in the field of trauma and orthopedic surgery, where national database evidence has highlighted concerns over the level of iatrogenic harm [3]. The largest proportion of surgical patient safety incidents were reported from the trauma and orthopedic specialty, with most errors relating to the implementation of care and on-going patient monitoring [3].…”

“…Particularly, key is improvement in the field of trauma and orthopedic surgery, where national database evidence has highlighted concerns over the level of iatrogenic harm [3]. The largest proportion of surgical patient safety incidents were reported from the trauma and orthopedic specialty, with most errors relating to the implementation of care and on-going patient monitoring [3]. It is for these reasons that foundation year doctors are particularly apt at targeting improvements in patient care, communication across the multidisciplinary team (MDT), local pathways, and IT systems.…”