The wrong type of metal plates were surgically implanted into a number of patients to treat broken bones, the NHS has admitted.
Patients at an unnamed NHS trust were found to have been given flexible plates meant for reconstruction rather than rigid plates designed for treating bone fractures, according to a patient safety alert released by NHS Improvement and the British Orthopaedic Association.
The alert comes following seven cases of patients at the unnamed NHS trust having been found to have the wrong types of bone plates (known as ‘fixation plates’) implanted to deal with a fracture. In two of these cases, the plate failed, leading the patients to require additional surgery.
While the cases identified so far only relate to one NHS trust, it is thought possible that similar errors could have occurred elsewhere due to widespread use of the same processes and procedures that may have contributed to the wrong fixation plates being used in these cases.
How did patients end up being implanted with the wrong fixation plates?
The seven cases of bone implant errors were identified following a systematic review of patient records in the wake of the two plate failures. The errors were found to involve different surgeons, scrub teams and theatres, suggesting the problem was systemic, rather than an issue with specific medical staff at the trust.
According to an NHS Improvement statement accompanying the alert: “Some organisations use an instrument tray system, where multiple plates and screws are contained on the same tray, which is replenished and resterilised after each operation. This creates a risk of confusing the types of plates used both at the point the tray is replenished and at the point a plate is selected for use.”
The alert highlighted that the processes and procedures used at the NHS trust where the errors occurred were similar to those used in many other organisations. The British Orthopaedic Association has therefore raised concerns that other organisations may have made similar errors in relation to fixation plates.
The potential for error may have been increased by a redesign of the flexible reconstruction plates, which made them more similar in appearance to the rigid plates intended for fractures.
What are the risks from having the wrong fixation plate for a bone fracture?
Because the plates intended for reconstruction are more flexible, there is more risk of them deforming, especially if they are placed under additional strain. This means they could fail to provide sufficient support to the patient’s bones while their fracture is healing, leading to an increased risk of further fracturing and the need for corrective treatment.
In the two cases where the wrongly implanted fixation plates failed, one occurred after the patient fell and the second following rehabilitation physiotherapy. In both cases, the plates were likely placed under additional stress that the more rigid plates intended to support a healing fracture could have withstood.
How can these kind of errors with fixation plates be avoided in future?
The patient safety alert specified action surgical staff could take to prevent the risk of similar errors in future, saying: “Since only a minority of orthopaedic procedures use reconstruction plates, storing them separately and fetching and opening them only
when specifically required provides a stronger barrier to inadvertent wrong selection.”
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