13.02.19
Thousands of X-rays to be reviewed amid fears of surgical errors
Thousands of NHS patients who had bone fractures repaired with a metal plate now need to have their X-rays reviewed after the NHS has admitted the wrong plates may have been used.
NHS Improvement (NHSI) has issued the national patient safety alert ordering trusts to review the X-rays of any patients who have had the surgery, and warned of the risk of harm from using the wrong selection of plates in fixing fractures.
The alert has been issued following seven ‘never events’ – serious, largely preventable safety incidents –that occurred at one trust, where patients with long bone fractures were repaired with the wrong plate.
In one case a patient fell and the plate buckled, requiring surgery, and in another case a patient required further surgery after their plate failed during their post-op physiotherapy.
The patients were fitted with plates designed for reconstruction that were inserted instead of rigid ones due to very similar appearance following recent changes to their design – and NHSI fears the same mistake may have been made elsewhere.
The alert was issued by NHSI alongside the British Orthopaedic Association who said it agreed with the need to act swiftly in the interest of patient safety, but stated that very few patients would likely be affected and the risk of harm is extremely low.
NHSI wants a stronger barrier to prevent inadvertently wrong selection, and the alert demands providers put an action plan in place to ensure the risk of confusing the types of plates is prevented and to ensure purchases are correct.
The health regulator is now asking hospitals to review cases going back to February 2018, with anyone affected before then likely to have already healed. It is expected around 5,500 cases will require checks.
NHSI’s national director for patient safety Aidan Fowler said: “Patients should not be alarmed and do not need to take any action themselves.
“The risk of harm is low and their local hospital will contact them if there is a chance that they have been affected.”
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