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

Sukhmeet S Panesar,¹ Andrew Carson-Stevens,² Sarah A Salvilla,¹ Bhavesh Patel,³ Saqeb B Mirza,⁴ Bhupinder Mann<sup>5

1</sup>Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK; ²Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK; ³National Patient Safety Agency, London, UK; ⁴Department of Trauma and Orthopaedic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, Hampshire, UK; ⁵Buckinghamshire Healthcare NHS Trust, Stoke Mandeville Hospital, Aylesbury, UK

Background: With 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.
Methods: Using 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).
Results: The 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 evidence: Despite 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.

Keywords: orthopedic surgery, patient safety incident, iatrogenic harm, error