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1.  The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach 
BMJ Open  2013;3(11):e003448.
Objective
The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery.
Design
Cross-sectional study (retrospective analysis of records in a database).
Setting
The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties.
Participants
We extracted all orthopaedic error reports from the system over 1 year (2009–2010).
Outcome measures
The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention.
Results
155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively.
Conclusions
The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.
doi:10.1136/bmjopen-2013-003448
PMCID: PMC3840344  PMID: 24270831
ORTHOPAEDIC & TRAUMA SURGERY; PUBLIC HEALTH
2.  Global Research Priorities to Better Understand the Burden of Iatrogenic Harm in Primary Care: An International Delphi Exercise 
PLoS Medicine  2013;10(11):e1001554.
Using a modified Delphi exercise, Aziz Sheikh and colleagues identify research priorities for patient safety research in primary care contexts.
Please see later in the article for the Editors' Summary
doi:10.1371/journal.pmed.1001554
PMCID: PMC3833831  PMID: 24260028
3.  How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement 
The Permanente Journal  2013;17(4):27-31.
Medical students have traditionally played a passive role in the delivery of health care. The Institute for Healthcare Improvement Open School members and leaders initiated the Ask One Question project in December 2011. Through a commitment to the project, students are learning to assume a unique position in health care settings, as both learners and caregivers. They are improving care at the bedside by asking a simple question: “How can I improve your stay today?” Using the Model for Improvement to adapt the Ask One Question concept for local use, medical students at Cardiff University (United Kingdom) asked 120 patients. A content analysis of those responses identified 89 issues across 4 broad areas for improvement, including communication issues (uncertainty about their care management and desire for more time with their health care professional); practical issues (assistance with tasks made difficult because of ill health); wider organizational and National Health Services requests; and medical needs (requiring medical or nursing intervention). A medical student, a clinical colleague, or the hospital organization could act on those issues. Actions ranged from attending to simple tasks (eg, finding spectacles) or basic care needs (eg, giving a drink) to suggestions requiring wider institutional change. On a simple but effective level, Ask One Question reflects good manners and is a demonstrable competency of patient-centered practice. It is a vehicle for enabling students to seek improvements in health care and initiate relevant actions to improve the patient experience at the bedside.
doi:10.7812/TPP/13-028
PMCID: PMC3854805  PMID: 24361017
4.  Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors 
Background
With scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS) in England and Wales is an underused resource which collects intelligence from reports about health care error.
Methods
Using methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs) and 95% confidence intervals (CIs).
Results
The largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%). Of those, 14,482/48,095 (30.1%) resulted in iatrogenic harm to the patient and 71/48,095 (0.15%) resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38); self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18); and infection control (OR 1.91, 95% CI 1.69, 2.17). We analyze these data to quantify the extent and type of iatrogenic harm in the specialty, and make suggestions on the way forward.
Conclusion and level of evidence
Despite the limitations of such analyses, it is clear that there are many proven interventions which can improve patient safety and need to be implemented. Avoidable errors must be prevented, lest we be accused of contravening our fundamental duty of primum non nocere. This is a level III evidence-based study.
doi:10.2147/DHPS.S40887
PMCID: PMC3615848  PMID: 23569398
orthopedic surgery; patient safety incident; iatrogenic harm; error
5.  Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors 
Background
Orthopaedic surgery is a high-risk specialty in which errors will undoubtedly occur. Patient safety incidents can yield valuable information to generate solutions and prevent future cases of avoidable harm. The aim of this study was to understand the causative factors leading to all unnecessary deaths in orthopaedics and trauma surgery reported to the National Patient Safety Agency (NPSA) over a four-year period (2005–2009), using a qualitative approach.
Methods
Reports made to the NPSA are categorised and stored in the database as free-text data. A search was undertaken to identify the cases of all-cause mortality in orthopaedic and trauma surgery, and the free-text elements were used for thematic analysis. Descriptive statistics were calculated based on the incidents reported. This included presenting the number of times categories of incidents had the same or similar response. Superordinate and subordinate categories were created.
Results
A total of 257 incident reports were analysed. Four main thematic categories emerged. These were: (1) stages of the surgical journey – 118/191 (62%) of deaths occurred in the post-operative phase; (2) causes of patient deaths – 32% were related to severe infections; (3) reported quality of medical interventions – 65% of patients experienced minimal or delayed treatment; (4) skills of healthcare professionals – 44% of deaths had a failure in non-technical skills.
Conclusions
Most complications in orthopaedic surgery can be dealt with adequately, provided they are anticipated and that risk-reduction strategies are instituted. Surgeons take pride in the precision of operative techniques; perhaps it is time to enshrine the multimodal tools available to ensure safer patient care.
doi:10.1186/1471-2474-13-93
PMCID: PMC3416713  PMID: 22682470
Patient safety; Errors; Orthopaedics; Trauma surgery; Quality improvement
6.  Minimising drug errors in critically ill patients 
Critical Care  2011;15(1):401.
doi:10.1186/cc9366
PMCID: PMC3222016  PMID: 21235830

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