Healthcare processes must be improved to reduce the occurrence of orthopaedic adverse events.

BACKGROUND: Many nonhealth industries have decades of experiences working with safety systems. Similar systems are also needed in healthcare to improve patient safety. Clinical incident reporting systems in healthcare identify adverse events but seriously underestimate the incidence of adverse events. A wide range of information sources and monitoring techniques are needed to understand and mitigate healthcare risks. AIM: The purpose of this study was to identify patient safety risk factors that can lead to adverse events in adult orthopaedic inpatients. DESIGN: A three-stage structured retrospective patient record review of consecutively admitted patients to the inpatient service of a large, urban Swedish hospital. METHOD: Records for all orthopaedic inpatients admitted during a 2-month period (n = 395) were screened using 12 criteria. Positive records were then reviewed in two stages by orthopaedic surgeons using a standardized protocol. Data were collected from the index admission and from subsequent visits or readmissions within 28 days of discharge. RESULTS: Sixty patients experienced 65 healthcare associated adverse events. Affected patients had a length of hospital stay double that of patients without adverse events. Adverse events were more common in patients undergoing surgical procedures and patients with risk factors for anaesthesia. Although 59 of the adverse events occurred in patients who underwent surgery, only nine of the adverse events were due to deficiencies in surgical/anaesthesia technique. The others were related to deficiencies in healthcare processes. The most common adverse events were hospital acquired infections (n = 20) and delayed detection of urinary retention (n = 13). Six adverse drug events involved elderly patients (≥65 years). CONCLUSION: Orthopaedic care is a high risk activity for its typically elderly, often debilitated patients. Reducing adverse events in orthopaedic patients will require more multidisciplinary, interdepartmental teamwork strategies that focus on healthcare processes outside the operating room.

Bony Bankart is a positive predictive factor after primary shoulder dislocation.

It would be a great advantage if it were possible to categorise the patients with first time dislocations to an initial treatment with the most beneficial outcome. MRI could be a useful method for finding lesions after shoulder dislocation. Fifty-eight patients with traumatic anterior shoulder dislocation were treated by closed reduction and were examined by MRI after a maximum of 2 weeks. The hemarthrosis or effusion present in the joint after the primary dislocation could be used as a contrast for arthrography to identify the lesions present on MRI. At follow-up more than 8 years later, the MRI findings were compared to the shoulder function, shoulder stability, Rowe score and Western Ontario Shoulder Instability Index (WOSI). Besides the age of the patient being above 30, the MRI findings analysed showed that an isolated fracture of the major tubercle, as well as a bony Bankart lesion are prognostic factors for a good functional result and a stable shoulder after a primary dislocation. The glenoid rim fracture was only detected on plain radiographs in 6 out of 10 findings on MRI. MRI findings of a gleniod rim fracture, equal to a bony Bankart lesion, were found to be a prognostic factor for stability and a good functional outcome.

The Western Ontario Shoulder Instability Index (WOSI): validity, reliability, and responsiveness retested with a Swedish translation.

BACKGROUND AND PURPOSE: The WOSI score questionnaire is a tool designed for self-assessment of shoulder function for patients with instability problems. We made a translation into Swedish and retested the score by analyzing the psychometric properties validity, reliability, and responsiveness. PATIENTS AND METHODS: 3 patient materials were used for the assessment: (A) a follow-up on a group of 32 patients more than 8 years after having primary posttraumatic shoulder dislocation. Evaluation of Pearson's correlation coefficient between WOSI and Rowe score and for test-retest reliability was made; (B) 22 patients, treated with a surgical stabilization of the shoulder at our department, were evaluated with Pearson's correlation coefficient between WOSI and EQ-5D, and between WOSI and a VAS-scale of general shoulder function. Also, Cronbach's alpha, effect size, and floor, and ceiling effects were analyzed; (C) 45 students with healthy shoulders (reference group) had their WOSI score determined. RESULTS: The construct validity (Pearson's correlation coefficient) was adequate (0.59) between the WOSI score and the Rowe score. The agreement with an ICC value (test-retest) for the WOSI score was excellent (0.94). Cronbach's alpha (internal consistency) was satisfactory, with 0.89 preoperatively and 0.95 postoperatively. All 22 patients in group B reported improvement in the WOSI score (mean 29%). Responsiveness was excellent, with an effect size of 1.67 for the WOSI score. There were no floor or ceiling effects for the Swedish WOSI score. The mean WOSI score from group C with 45 normal healthy shoulders was 96%, with no floor but high ceiling effects. INTERPRETATION: WOSI score does not require an examination of the patient and can be administered by mail. The high ICC and sensitivity makes it able to monitor an individual patient's progress. At this retest, the WOSI score has good validity, a high degree of reliability, and a high degree of responsiveness, all at the same level as in the original publication. We recommend the WOSI when evaluating patients with instability problems.

The Bankart repair versus the Putti-Platt procedure: a randomized study with WOSI score at 10-year follow-up in 62 patients.

BACKGROUND AND PURPOSE: This randomized study compared clinical results after surgery for posttraumatic shoulder instability with either an anatomical repair or an older, less anatomical but commonly used method. The less anatomical procedure has been considered quicker and less demanding, but it has been questioned regarding the clinical result. We therefore wanted to compare the clinical outcome of the two different procedures. Our hypothesis was that the anatomical repair would give less residual impairment postoperatively. METHODS: Patients with anterior posttraumatic shoulder instability were consecutively randomized on the day before surgery to either a Bankart repair using Mitek GI/GII anchors combined with capsular imbrication (B) (n = 33) or a Putti-Platt procedure (P) (n = 33). Follow-up was performed by examination at 2 years and using a self-evaluation score at 10 years. RESULTS: At the 2-year follow-up, we found no difference in muscle strength between patients treated with the two surgical methods and there were no statistically significant differences in the Rowe scores (mean 90 units for both groups). Compared to preoperatively, the decrease in external rotation 2 years after surgery was 10 degrees in the P group and 3 degrees in the B group (p = 0.03). 10 years after surgery, 62 of 66 patients replied to a questionnaire sent by mail. It included a self-evaluating quality of life score for shoulder instability (WOSI) for evaluation of their shoulder function. In the P group 15 patients and in the B group 19 patients reported they had experienced either a redislocation or a subluxation with a new feeling of shoulder instability. Mean WOSI score was similar in the P and B groups: 80% and 83%, respectively. The WOSI score was 87% for patients with stable shoulders (n = 28) and 77% for those with unstable shoulders (n= 34) (p = 0.005). INTERPRETATION: With assessment of pain and general shoulder function, only a small difference was found between the two methods. The WOSI scores for stable shoulders indicated that some shoulders still had impaired function even though the shoulders had become stable.

Identification of adverse events at an orthopedics department in Sweden.

BACKGROUND AND PURPOSE: Adverse events (AEs) are common in acute care hospitals, but there have been few data concerning AEs in orthopedic patients. We tested and evaluated a patient safety model (the Wimmera clinical risk management model) and performed a three-stage retrospective review of records to determine the occurrence of AEs in adult orthopedic inpatients. METHODS: The computerized medical and nursing records of 395 patients were included and screened for AEs using 12 criteria. Positive records were then reviewed by two senior orthopedic surgeons using a standardized protocol. An AE had to have occurred during the index admission or within the first 28 days of discharge from the Orthopedics Department. Screening of additional systems for reporting of AEs was also carried out for the same period. The number of patients suffering an AE and the number of AEs were recorded. RESULTS: Altogether, 60 (15 %) of 395 patients checked in the screening of records experienced 65 AEs (16%) due to healthcare management. Of the 65 AEs, 34 were estimated to have a high degree of preventability. 47 of the 65 AEs occurred during the index admission and 18 within 28 days of discharge. In screening of local and nationwide reporting systems for the same patients, 4 additional AEs were identified-2 of which were previously unknown. 67 different AEs were detected by using the Wimmera model (17%) INTERPRETATION: Using the Wimmera model with manual screening and review of records, many more AEs were detected than in all other traditional local and nationwide reporting systems used in Sweden when screening was done for the same period.