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Title: Using a national repository of error reports to obtain insights into the safety of orthopaedic surgery
Author: Panesar, Sukhmeet S.
ISNI:       0000 0004 6425 3701
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 2014
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Introduction: Almost a decade ago, there was a call to establish patient safety reporting systems that would operate at local, regional and national levels; it was envisaged that these would help healthcare professionals and organisations to learn from mistakes and lead to the development of interventions aimed at mitigating against these errors. This policy call led to the creation of the National Reporting and Learning System (NRLS). It however remains unclear whether reporting systems result in safer care. Specialties such as orthopaedics pose a high potential risk of iatrogenic harm, and this clinical area therefore represents a useful exemplar in which to study the opportunities offered by this national repository of errors to improve the safety of orthopaedic care provision. Aims: The aims of this thesis were to: • understand the opportunities offered by the NRLS to ascertain the frequency, types and causes of errors in orthopaedic surgery • develop the risk prediction potential of the system • offer critical reflections on the role of reporting systems for improving the care received by orthopaedic patients. Methods: Data on orthopaedic entries over the time period 2005-2008 were extracted from the National Patient Safety Agency's NRLS. Given the high volume of orthopaedic error reports, an approach was developed to prioritise areas most likely to result in patient harm. This approach was used to select four key areas, and examples of work undertaken to reduce the harm associated with orthopaedic surgery in these areas are presented. A detailed assessment of all orthopaedic deaths was also undertaken using an inductive approach of content analysis. A key aspect of this thesis was the creation of the Orthopaedic Error Index for hospitals, which allows a national assessment of the relative safety of provision of orthopaedic surgery. It uses existing principles of benchmarking to identify outlier hospitals where a large proportion of harm occurs compared to other hospitals. Results: There were 48,971 free-text reports of orthopaedic errors made available for analyses. These reports were grouped into 15 categories, which have been used since inception of the NRLS. A method of prioritising these categories of errors was developed which yielded an odds ratio of the most harmful category of errors compared to the others; these included errors associated with implementation of care and on-going monitoring/review [OR = 2.55 (95% CI 2.49, 2.62)]; self-harming behaviour [OR = 1.60 (95% CI 1.30, 1.96)]; infection control [OR= 1.50 (95% CI 1.41, 1.61)]; treatment, procedure [OR= 1.31 (95% CI 1.22, 1.42)]; and patient accidents [OR = 1.02 (95% CI 0.99, 1.05)]. In each of these error categories, where possible, topics were selected where there was a paucity of national guidelines on delivering safer orthopaedic care. All the deaths (n = 257) were also reviewed (2005-2009). Four main thematic categories emerged: (1) stages of the surgical journey - 62% of deaths occurred in the post-operative phase; (2) causes of patient death - 32% were related to severe infections; (3) reported quality of medical interventions - 65% of patients experienced minimal or delayed treatment; and (4) skills of healthcare professionals - 44% of deaths had a failure in non-technical skills. A single error could have multiple themes, hence all errors did not add up to 100%. National alerts were then produced to mitigate risks associated with the use of digital tourniquets, hip cement, and slips, trips and falls. Data from 155 hospitals were used to create an Orthopaedic Error Index (OEI) which was normally distributed. The mean OEI was 7.09/year (SD 2.72); five hospitals were identified as outliers, lying three standard deviations above the mean OEI. This is the first time that a direct measure of patient safety has been created and used. Discussion: Reporting systems such as the NRLS offer a potentially important approach for orthopaedic surgeons to better understand the safety considerations of their work. This work has shown that content analyses and prioritisation of errors can be beneficial for large databases and can alert orthopaedic surgeons to practices of unsafe care. Subsequent solutions to mitigate against these errors can furthermore be developed. It is also possible to use the NRLS for risk prediction and identify, earlier on, any hospitals that have significant variation in the severity and propensity of errors. It is hoped that this work will catalyse efforts by a few in orthopaedic surgery to recognise that unsafe care is a problem and needs to be better understood and appropriate solutions developed.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available