Safety Alert Over Wrong Fracture Fixation Plates

Peter Russell

February 13, 2019

A patient safety alert has been issued over concerns that wrong metal plates may have been used for fixation of fractures.

NHS Improvement said it had been made aware of seven incidents at one NHS trust where the wrong type of plate had been selected.

The alert, issued jointly with the British Orthopaedic Association (BOA), called on hospitals providing orthopaedic surgery in England to review X-rays for patients who have had surgery where metal plates were used to fix certain limb fractures, including the forearm, femur, humerus, and tibia.

Seven Cases Identified in One Trust

NHS Improvement said it was made aware of seven cases where reconstruction plates were used instead of dynamic compression plates (DC plates). 

In two of those cases, the plate failed: the first after the patient fell, and the second following rehabilitation physiotherapy. Both patients required further surgery.

Although all seven incidents were identified in one unnamed trust, the BOA said it was concerned that other organisations might have been affected. The seven cases involved different surgeons, scrub teams, and theatres. A review of records showed that the processes and procedures used were similar to those in other hospitals, it said.

Plate Re-design May Have Caused Error

The error was attributed to recent changes in the design of some reconstruction plates which have made it easier to confuse types of plates that were once more visually distinct. That may have been compounded by an instrument tray system used by some organisations where multiple plates and screws were contained on the same tray.

To prevent inadvertent wrong selection, the safety alert asked providers to put an action plan in place to purchase reconstruction plates as individually sterilised packs, and to ensure the packs are stored separately from DC plates. Also, each pack should only be selected and taken out of its sterile packaging when specifically needed.

Hospitals have also been asked to:

  • Identify a clinical lead within orthopaedics to prepare an action plan in response to the alert

  • Identify all patients who have had a plate fitted since 1st February 2018 for treatment of long bone shaft fractures and undertake a retrospective review of patient X-rays to ensure the correct plate was fitted to stabilise shaft fractures of the humerus, forearm, femur, or tibia

  • Agree an appropriate plan of care for a patient where a reconstruction plate was wrongly used

  • Report any wrong use of a plate as a 'never event'

All steps must be completed by 10th May 2019, the alert said.

'No Cause for Patient Alarm'

Dr Aidan Fowler, national director for patient safety at NHS Improvement, said: "When we identify patient safety issues it is important that we act to reduce the risk of them being repeated. 

"We are asking all hospitals in England who provide orthopaedic surgery to review X-rays for their patients who have had surgery involving plates in the past year.

"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."

The BOA estimated that 30 to 40 patients per NHS trust would have had this type of surgery since February 2018.


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