Open Access Highly Accessed Research article

Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors

Sukhmeet S Panesar123*, Andrew Carson-Stevens4, Bhupinder S Mann5, Mohit Bhandari6 and Rajan Madhok7

Author Affiliations

1 Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, Praed Street, London, W2 1NY, UK

2 Centre for Population Health Sciences, The University of Edinburgh, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK

3 National Patient Safety Agency, 4-8 Maple Street, London, W1T 5HD, UK

4 Department of Primary Care and Public Health, Cardiff University, 2nd Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK

5 Southmead Hospital and Avon Orthopaedic Centre, North Bristol NHS Trust, Westbury-on-Trym, Bristol, BS10 5NB, UK

6 Center for Evidence-Based Orthopaedics, McMaster University, Department of Orthopaedic Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON, L8S4L8, Canada

7 Parkway Business Centre, NHS Manchester, Parkway 3, Princess Road, Manchester, M14 7 LU, UK

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BMC Musculoskeletal Disorders 2012, 13:93  doi:10.1186/1471-2474-13-93

Published: 8 June 2012



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.


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.


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.


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.

Patient safety; Errors; Orthopaedics; Trauma surgery; Quality improvement