Incidence and preventability of adverse events in an orthopaedic unit: a prospective analysis of four thousand, nine hundred and six admissions

Purpose: We aimed to identify the incidence and preventability rate of adverse events (AEs) occurring in a specialty orthopaedic unit.

Methods: Four thousand nine hundred and six consecutive in-patient admissions over six months in an orthopaedic unit were prospectively analysed. The total indoor patient capacity was segregated into 25-bed units each, and AEs were recorded on a daily basis by two observers. Each event was assessed by allotting a causation score (1-6), with a score of ≥ 4 implying a systemic/individual failure of healthcare provision. A preventability score (1-6) was allotted and scores ≥ 4 were considered to be preventable.

Results: Four hundred and sixty-seven patients (9.5 %) suffered a total of 529 AEs, including 127 readmissions; 49 patients suffering multiple events. Three hundred and thirty-three (62.9 %) events had a causation score of ≥ 4, indicating a failure of healthcare delivery systems. Three hundred and one (56.8 %) events could have been prevented with better regulation and adherence to management protocols. Hospital-acquired infections were the most common event, with surgical-site infection in 102 cases (19.2 and 2 % overall) and catheter-associated urinary tract infections noted in 45 (8.5 %) patients. Medical events included seven deep vein thrombosis, two pulmonary embolisms, five myocardial infarctions and one stroke. AEs occurred 56.3 % in the ward, 4.3 % in the intensive care unit (ICU), 6.2 % in the emergency room, and 9.0 % in the operating theatre.

Conclusion: This prospective study documented an adverse event rate of 9.5 %, of which 56 % were preventable. AEs occurred in all stages of treatment care, emphasising the need for vigilance during the entire treatment process.