Thousands of patient X-rays are to be reviewed by more than 140 hospital trusts amid fears the wrong metal plates were used during orthopaedic operations.
NHS Improvement has issued a national patient safety alert warning trusts to review the X-rays of any patient who had surgery with a metal plate for a long bone fracture since February 2018.
The alert has been issued after seven never events were reported by one NHS trust following a review which found patients were fitted with the wrong type of metal plate. The review was prompted after two patients needed surgery when their metal plates buckled.
In total, more than 5,600 patients are thought to be affected by the alert, with the British Orthopaedic Association estimating 30 to 40 patients per NHS trust.
Any patients identified as having the wrong plate fitted may need further surgery and will have their case reported as a never event.
The problem has been caused by a change in the design of reconstruction plates which means they now look similar to dynamic compression plates. The two types of plates have different strengths of rigidity and are not interchangeable.
In the alert, issued yesterday, NHS Improvement said: “Although the seven incidents mentioned were found by one organisation following a systematic review of patient records after the index cases occurred, the cases involved different surgeons, scrub teams and theatres and all the processes/procedures used were similar to those in many other organisations.
“The British Orthopaedic Association is concerned that other organisations may have inadvertently used the wrong type of fixation plate, putting patients at risk until their fractures have fully healed and potentially requiring them to undergo corrective treatment.”
Aidan Fowler, national director for patient safety said: “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.”
Trusts have been given three months to identify all patients who have had plates fitted since February last year and to review their X-rays report any incidents. They must also change their theatre processes to prevent the two types of plates from being confused.
NHSI has suggested hospitals only purchase reconstruction plates that come in individual sterilised packs which should be stored separately and used only when specifically required during surgery.
NHSI also praised the trust who reported the never events for its diligence although the regulator declined to identify the trust.
It said the trust’s “diligence was instrumental in identifying the potential for national action to protect other patients who may have been affected elsewhere”.