Patient safety in orthopaedics

Medical errors, affected sites, and adverse consequences among patients in the orthopaedic department: Does age matter?

Background

Orthopaedics have become the focus of research on patient safety due to the high incidence of medical errors. Previous studies were based on all orthopaedic patients and rarely conducted empirical analyses from the perspective of age. This study aimed to fill the academic gap in the age variable by comparing medical errors, affected sites, and adverse consequences in orthopaedic patients.

Methods

This retrospective study included 329 litigation claims against orthopaedists using data from China Judgments Online. First, we performed computer crawling and screened 5,237 litigation documents using keywords, including medical errors. Second, 2,536 samples were retained through systematic random sampling, and 549 irrelevant cases were deleted after manual reading. Finally, three clinicians from different medical departments selected 329 incidents related to orthopaedics for further analysis, according to the description of the lawsuits. Three other professional orthopaedists evaluated the patients' ages, affected sites of medical errors, and adverse consequences.

Results

The greatest number of medical errors was observed in the joints (30.43%) for all orthopaedic patients. However, adult patients (aged 18-60 years) were most susceptible to errors in the extremities (30.42%). A higher rate of complications was associated with a higher rate of morbidity/mortality for the corresponding patients. Medical errors correlated with complications occurred in the following sites: joints (15.38%), extremities (12.50%), spine (16.95%), multiple sites (15.38%), and hands and feet (14.81%). In addition to surgical errors, over 10% of all orthopaedic patients experienced missed diagnoses. The incidence of insufficient adherence to informed consent obligations was 13.5% among adult patients and was much higher in paediatric and older adults patients. When orthopaedic patients suffered from medical technical errors, iatrogenic mortality/morbidity would decrease by 0.3% for one unit increase in age.

Conclusion

Dividing patients into different ages demonstrated diverse results in terms of medical errors and affected sites. Negligence in diagnosis and examination can be fatal factors that endanger safety, and complications may cause morbidity/mortality. When patients suffered from technical errors, age is inversely proportional to mortality/morbidity. Special attention needs to be paid to technical errors in the younger older adults population (60-64 years old), which has inspired implications in promoting aging and public health.

Safe surgery: analysis of physicians' adherence to protocols, and its potential impact on patient safety

OBJECTIVES

: to identify surgeons' knowledge and compliance rate to the Safe Surgery Protocol, as well as to assess the incidence of surgery-related adverse events, including patients' knowledge about the protocol.

METHODS

this is a cross-sectional and prospective study. An instrument was developed to collect the socio-graphic characteristics of sixty-eight surgeons and residents, their knowledge and adherence to the safe surgery protocol. Eighty-two patients were assessed regarding their awareness about the surgical procedure. The operating environment was also evaluated. Descriptive statistics and the odds ratio are presented.

RESULTS

the surgeons, despite their previous contact with the protocol throughout the graduation period, were poorly compliant with it. Adverse events such as the use of uncalibrated equipments or the presence of foreign bodies in several equipments such as drills and cautery pens were identified. In addition, some of the adverse events were identified and fixed, after patients had already been anesthesized, but before the beginning of the surgical procedure. Patients demonstrated knowledge about the operation they would undergo, but they did not know about its duration, and they were not introduced to the surgical team.

CONCLUSION

there were failures in the dynamics and compliance regarding some phases of the protocol, which may impact the laterality errors and patient safety.

The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults

BACKGROUND

Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults.

DESIGN

A pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years.

SETTING

Recruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation.

PARTICIPANTS

Adults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck.

INTERVENTIONS

The choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups.

MAIN OUTCOME MEASURES

The primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected.

RESULTS

The mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0-48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) -1.33 to 2.84; p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses.

CONCLUSIONS

Current surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50850043.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.

The WHO Surgical Safety Checklist: knowledge and use by Brazilian orthopedists

Objective

The research examined Brazilian orthopedists’ degree of knowledge of the World Health Organization Surgical Safety Checklist.

Methods

A voluntary survey was conducted among the 3231 orthopedists taking part in the 44th Brazilian Congress of Orthopedics and Traumatology in November 2012, using a questionnaire on the use of WHO Surgical Safety Checklist. A statistical analysis was done upon receipt of 502 completed questionnaires.

Results

Among the 502 orthopedists, 40.8% reported the experience of wrong site or wrong patient surgery and 25.6% of them indicated “miscommunication” as the main cause for the error. 35.5% of the respondents do not mark the surgical site before sending the patient to the operating room and 65.3% reported lack of knowledge of the World Health Organization (WHO) Surgical Safety Checklist, fully or partially. 72.1% of the orthopedists have never been trained to use this protocol.

Discussion

Medical errors are more common in the surgical environment and represent a high risk to patient safety. Orthopedic surgery is a high volume specialty with major technical complexity and therefore with increased propensity for errors. Most errors are avoidable through the use of the WHO Surgical Safety Checklist. The study showed that 65.3% of Brazilian orthopedists are unaware of this protocol, despite the efforts of WHO for its disclosure.