It may not seem a matter for celebration but the NHS Improvement Safety Alert system is working – all NHS Trusts have been alerted to problems relating to the use of two different fracture plates and asked to review patient records dating back to February 2018.
The reason for celebrating is that it was the unnamed Trust’s procedures for the systematic review of patient records after fracture plates in two patients failed that were responsible for uncovering the cause of the failure and identifying other patients at similar risk. Some may argue that the cause of the failure (the misidentification of two different types of fracture plates) was entirely avoidable – and, indeed, this may be true – but it is the fact that once the problem had been identified, the hospital’s procedures for such an event were followed and further such errors prevented.
Reputations at stake
Mistakes occur in every organisation but in the health system there is always the danger that a mistake could cause irreparable harm or even death. This is why health systems, the world over, have adopted the same approach to safety as the airline industry where every engineering failure has a potentially catastrophic outcome, giving it a powerful incentive to create a carefully calibrated, process-driven approach to manufacturing. However, as the fatal crashes of two Boeing 737 aeroplanes in the last six months demonstrate, not even the most safety conscious industry in the world is immune to failure. Nonetheless, the industry’s future reputation will depend on how Boeing deals with the aftermath and its commitment to learn from mistakes made.
Patient Safety Alert issued promptly
In the case of the misidentified fracture plates, the NHS Trust alerted NHS Improvement (NHSI), which, in turn and in conjunction with the British Orthopaedic Association (BOA), issued a Patient Safety Alert to all NHS Trusts that undertake orthopaedic surgery to repair fractures, with recommendations on how to avoid a similar event occurring. As a result of the Trust’s prompt response to the realisation that two patients had been fitted with the wrong plates (and had to undergo corrective surgery as a result of the injuries they sustained) a further five patients were also found to have had the wrong plates inserted and underwent remedial surgery. The seven incidents were reported to NHS Improvement as ‘never events’ as required under the protocol.
Similar design, different application
The root of the error lay in the change to the design of the more flexible plate used for reconstruction, making it very similar to, and thus easy to confuse with, the more rigid dynamic compression (DC) plate used for fractures of long bones. As fractures can take months to heal, it is imperative that the correct plate is used to give the necessary stability to the injured limb and speed up the healing process. Plates used for reconstruction are more rarely used but, it transpired, were present on the same instrument tray in theatre as the DC plates and, because the designs were now very similar, the surgeons used the wrong one. NHSI and the BOA have now issued guidance, recommending that reconstruction plates are kept in separate, clearly identified, sterile packs and only sent for when actually required.
Prompt action secures patient confidence
The prompt action taken means that if surgeons in other Trusts have made the same mistake, the affected patients can be identified and remedial action taken before more serious injury is sustained. Whether or not there is any evidence of negligence will depend on how individual Trusts and their orthopaedic surgical teams handle fracture surgery; to date, it appears that the Trust in question was using a procedure common to other organisations so will probably pass the ‘reasonable person’ test. However, the main point of this story is that a quick, decisive response when something does go wrong is crucial to maintain patient confidence – and the willingness to apologise and make amends.