Patients seek more and more actively compensation for treatment injuries, accidents, infections, and even because of unsatisfied results. Injuries or mistreatment are quite frequently seen in orthopaedic surgery, because operations are increasing and unsatisfactory results can be easily recognised from radiographic documentation.

Compensation can be theoretically sought by three main routes: directly from the orthopaedic surgeon or his insurance company, secondly, from the institution where he is working (or its insurance company) and thirdly, from a statutory system if there is one available. The first two direct compensation mechanisms are based on direct link between the patient and the physician involved. A statutory system can be universal and act more as a no fault compensation system.

Statutory patient insurance was introduced in1987 in Finland (Patient Insurance Act). This act covers all medical treatment, both public and private care in Finland including examination, surgical and nonoperative treatment, inpatient ward treatment, physiotherapy, rehabilitation as well as patient transportation.

All hospitals and companies dealing with medical care need to be insured. The institutions or companies responsible of the medical work owe the policyholder status. Therefore workers in the medical field need not to make their own insurance agreements nor pay any insurance fees to the companies.

The Finnish Patient Insurance Centre handles all claims in Finland, about 7.000 cases yearly, of which about 2.000 will give compensation to the patients. An independent Patient Injury Board stated by the Ministry of Health supervises the Centre.

So far, orthopaedics and traumatology has been the leading speciality in producing injuries. The injuries are divided into six subgroups: 1) treatment injury, 2) infection, 3) equipment-related injury, 4) accident related injury, 5) wrong delivery of pharmaceuticals and 6) unreasonable injury (severe complication with permanent disability after accurate treatment).

The evaluation of patient injury is concentrated on the case itself. The personnel involved to the treatment will not be accused or sued whenever a patient injury has been recognised. This no-guilt principle has been adopted well in Finland.

In the treatment injuries the level of acceptable care is determined by standard of an experienced professional of that speciality he/she represents. That means that an orthopaedic operative or diagnostic procedure will be evaluated compared to the level, which a graduated and experienced orthopaedic surgeon could have normally reached. Infection injuries are considered acceptable and do not lead to compensation when being superficial, or if a deep infection heels within a couple of weeks or months with adequate treatment and without any permanent disability. Traumatic accidents are quite rare as well as breakage of medical equipment and error of delivery of pharmaceuticals in pharmacies. Unreasonable injuries are seen a few yearly.

The prerequisite for compensation is that there has to be an objectively recognised harm to the patient due to a diagnostic or treatment procedure. Patient insurance covers the following costs: 1) medical treatment expenses, 2) other necessary expenses caused by the injury, 3) loss of income on maintenance, 4) pain and suffering, 5) permanent functional defect, and 6) permanent cosmetic injuries.

In 2004 the total costs of compensation paid was 24.2 million e (public health care 88% and private health care12%).

The yearly claim and compensation data is used for comparative analysis between the hospital districts and given also to the medical and surgical societies in order to enhance medical knowledge and skills and prevention of similar injuries in the future.

Patients owe still the possibility to sue the hospital or doctors involved. However, these cases will be normally handled by the Patient Insurance Centre and not by the medical personnel individually. In fact, the amount of trials against medical units or personnel has diminished dramatically after adoption of the Patient Insurance Act in Finland.

In Sweden 99 % of all complaints against doctors are handled by a public authority, The Medical Responsibility Board (HSAN). This way it is very rare fore a medical complaint to reach the judicial courts in Sweden. HSAN is a national authority that assesses medical negligence. If health care staff is at fault, the Board can take disciplinary action against them.

The Board is made up of nine members. The chairman is a lawyer with judicial experience and the other members have experience from various sectors of the health services. Anyone who is or has been a patient can file a complaint to HSAN. The National Board of Health and Welfare, the Parliamentary Ombudsman and the Chancellor of Justice can also file complaints to HSAN. The complaint must contain details of the actual examination, care or treatment referred to, when and where it took place and, if possible, who was at fault and what the fault is considered to be. HSAN must be informed of the subject of complaint within two years of the incident’s occurrence. If this is not the case, disciplinary responsibility will have lapsed.

HSAN’s decisions are always public. A case is prepared by getting the opinion of the accused doctor and a copy of the patient records.

When a case has been prepared medical experts with links to HSAN review it. HSAN subsequently examines the case and arrives at a decision. The chairman alone examines certain cases following a review by medical experts. Copies of the decision are sent both to the person who filed the complaint and those to the person(s) cited.

If the person filing the complaint is not happy with the decision, it may be appealed. The appeal must be lodged within three weeks from the date the decision is made public. The court of appeal is the county administrative court.

HSAN does not handle requests for economical compensation. If the plaintiff wants money he/she has to go to court. This happens extremely seldom.

HSAN handles about 3000 cases a year and in less that 6–10 % a decision against the accused is made. 70 % of the cases concern doctors and 30 % dentists, nurses and others. The number of orthopaedics cases is about 300 per year and a ruling against the surgeon happens in less than 10 %. The complaints in orthopaedics concern clinical examination, faulty diagnostics (usually that x-rays were not taken), faulty treatment and misconduct. Most of the cases in orthopaedics originate in the emergency department.

Litigation costs are significant and increasing annually within the National Health Service (NHS) in England.

The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action.

A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed.

The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465.

Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims.

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of “failure to warn”, i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on “failure to warn” and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA. Cite this article: Bone Joint J 2020;102-B(5):550–555

The February 2015 Oncology Roundup. 360 . looks at: Achieving global collaboration; A new standard for limb salvage; Inoperable chondrosarcoma and chemotherapy; Soft-tissue sarcoma and adjuvant chemotherapy; Missed diagnoses and malpractice in sarcoma; Radiofrequency and cartilage tumours

The aim of this paper is to stress that an expert providing medico-legal opinion in matters relating to medical malpractice, workers compensation, transport accident and other injuries should preferably be a recognised expert in the field by virtue of knowledge, training, qualification and experience, free from bias as far as is possible and willing to provide evidence if called to court. Based on over ten years experience of conducting what is now largely a medicolegal practice and recently having obtained a Post Graduate Diploma in Health/Medical Law from Melbourne University and with approximately 800 assessments conducted yearly over that period, requirements for taking a comprehensive history, carrying out a thorough physical evaluation as well as assessment of all appropriate investigations and writing a “stand alone” medicolegal report will be outlined. Also included in the final opinion should be comments on opinions given by other experts. One should also include the summarised opinion in the world literature relating to the main issue. Finally, just as a judge does when giving his judgement the reasons underlying the opinion should be fully explained. Judges throughout Australia conducting medical lists are concerned that many medical assessments appear to be biased towards the party requesting and paying for the report; ways of reducing bias will be suggested. Finally the author will give his views on the value of expert medical panels independently appointed by the courts through the learned medical colleges giving their opinion on liability and whole person impairment in medical malpractice claims, and similar to medical panels currently assessing workers compensation injury in most states in Australia

Introduction: Patient education and informed consent are areas of clinical practice that are taking an ever-increasing proportion of a surgeon’s time and effort. The expectation is that this trend will continue, as medical malpractice litigation becomes more commonplace. Patients are also requiring increased access to medical information to help facilitate decisions about their healthcare. With the increasing use of computers and improvements in technology modules to aid patients’ understanding have become available and may prove useful in patient education. Method: A computer-based multimedia module of total hip replacement (THR) has been developed. These involve three-dimensional (3D), animated computer graphics with text and spoken word. A questionnaire based on educational models was designed to test ease of use and patients’ comprehension after viewing the module. Results: A pilot study involved 20 patients each awaiting elective surgery for THR. The results showed a good comprehension and understanding of the nature of the surgery and the possible complications. Conclusions: We have shown that a 3D-multimedia patient education module improved patients’ understanding of THR surgery and its possible complications. The use of 3D multimedia modules has the potential to save the surgeon time whilst ensuring that his/her patients have given informed consent to their forthcoming surgery. It is hoped that better-informed consent may equate to a reduction in medical malpractice activity and thus insurance premiums

Introduction. While THA is associated with positive results and long-term improvement in patient quality of life, outcomes are nonetheless associated with adverse events and post-procedural deficits related to discrepancies in leg length (LLD), offset and cup placement. Post-THA errors in these parameters are associated with gait alteration, low back pain and patient dissatisfaction. Such discrepancies often necessitate revision and increasingly lead to medical malpractice litigation. Maintaining accuracy in post-surgical leg length, offset and cup placement during THA is difficult and subject to error. The sensitivity of these factors is highlighted in studies that have shown that a change of as little as 5 degrees of flexion or abduction can induce alterations in leg length of up to several millimeters. Similarly, positioning of implants can alter global and femoral offset, affecting abductor strength, range of motion and overall physical function. Compounding the biochemical issues associated with inaccurate leg length are the costs associated with these deficits. Traditional freehand techniques of managing intra-operative parameters rely on surgeon experience and tissue tensioning to manually place components accurately. These methods, however, are only able to assess leg length and are subject to inaccuracies associated with patient movement or orientation changes during surgery. Mechanical methods of minimizing post-surgical discrepancies have been developed, such as outrigger or caliper devices, although these methods also address leg length only and provide poor feedback regarding offset and center of rotation, therefore providing insufficient data to accurately achieve appropriate post-surgical leg length. Computer-assisted navigation methods provide more data regarding leg length, offset and center of rotation, but are limited by their cumbersome nature and the large capital costs associated with the systems. The Intellijoint HIP. ®. surgical smart tool (Intellijoint Surgical, Inc., Waterloo, ON) is an intra-operative guidance tool that provides surgeons with real time data on leg length, offset and center of rotation, thereby allowing for confident selection of the correct implant in order to ensure appropriate post-surgical biomechanics. The early clinical results from an initial cohort of patients indicate that Intellijoint HIP. ®. is safe and effective. No adverse events were reported in the initial cohort, and the smart tool was able to measure surgical parameters to within 1mm when compared to radiographic measurements. With training cases removed, 100% of cases had a post-procedure leg length discrepancy of less than 5mm. This paper describes the indications, procedural technique and early clinical results of the Intellijoint HIP. ®. smart tool, which offers a safe, accurate and easy-to-use option for hip surgeons to manage leg length, offset and cup position intra-operatively

Analysis of orthopaedic malpractice claims has shown that highest impact allegations (highest payment dollars per claim) were those that were related to failure to protect anatomic structures in surgical fields. The prevalence of subclinical peripheral neurologic deficit following reverse and anatomic shoulder arthroplasty has been reported to be 47% and 4%, respectively. We propose the following five rules in order to avoid neurovascular injury during shoulder arthroplasty cases:. Pre-operative planning would assure a smooth operation without intra-operative difficulties. Adequate planning would include appropriate imaging, obtaining previous operative reports, complete pre-operative neurovascular examination and requesting the necessary operative equipment. Tug test: It is crucial to palpate the axillary nerve and be aware of its location. The tug test is a systematic technique for locating and protecting the axillary nerve. Neuromonitoring has been utilised in shoulder surgery in the past. Nagda et al showed that nerve alerts during shoulder arthroplasty occurred 56.7% of the time and 50% of the events were with the arm in abduction, external rotation and extension; 76.7% of signals returned to normal with retractor removal and change in arm positioning. We recommend removing all retractors and returning the arm to neutral position several times during surgery, especially during the glenoid exposure when the arm is in abduction and external rotation. Newer commercially available nerve stimulators are extremely useful in locating and protecting neurovascular structures. We recommend brachial plexus exploration and axillary nerve dissection with the aid of a nerve stimulator in all revision cases. Availability of a nerve/microvascular surgeon as an assistant in revision cases for brachial plexus exploration using a microscope is crucial for successful revision surgery

A 5 year review of factors instigating malpractice claims and likely to result in a payout. Possible lessons for the future. Background. During 2002-2007 over 300,000 patients underwent knee arthroplasty (KA) in England and Wales, from which 204 cases of litigation were processed costing in excess of £5million. The complications associated with primary KA are well documented, however those instigating litigation in the UK are not known. This study assessed trends in litigation over the past 5 years identifying instigating factors and success rates to highlight areas for further improvement in patient information and surgical management. Methods. Data from the NHS Litigation Authority on claims following KA unrelated to trauma between 2002 and 2007 were obtained and analysed. Results. 246 claims were made, 171 (70%) were settled of which 81 (47%) resulted in a successful claim. The total cost to the NHS was £5,257,228. The number of claims has increased from 26 in 2002 to 67 in 2007, while the rate of successful claims decreased from 58% to 9%. The three most common instigating factors were ongoing pain(24%), operator error(23%) and infection(10%). The factors with greatest successful claims were operator error(80%), vascular injuries(75%), failure of post-operative care(55%). Conclusion. Litigation claims following KA are increasing, although there rate of success is decreasing. Operator error, vascular injuries and failure of post-operative care are predictors of a successful claim. However failure to consent adequately, adhere to policies and standard practice can result in a successful claim. Protecting patients intra-operatively and maintaining high technical expertise while implementing policies and informed consent decreases the litigation burden to the NHS

Aims

Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients.

The aim is: to point out, in respect of Italian case law trends, the concept and the boundaries of surgeon malpractice liability in evaluating and implanting new prosthesic materials. The surgeon is liable for damages caused by fraudulent intention or fault during his clinical and operating activity. In a civil perspective, it could be the result of either a breach of a contract or a tort, depending on the existing relationship between the surgeon and the patient; but in both case there might be a serious inexperience or a light imprudence or negligence to admit a fair compensation for damages. While in a criminal perspective, the personal injuries might be the result of a serious fault also in the area of imprudence and negligence to admit the application of criminal sanctions. Of course, personal liability of surgeon stands by vicarious liability of health unit. Civil sanctions are more effective than criminal sanctions, not only because they have a wider area of application, but also because they are more incisive in quantitative terms, considering the new guidelines on pecuniary and biological damages that make out, at the same time, a compensatory and punitive function. The surgeon, to be sure not to be affected by civil and criminal actions, might inform the patient about the operating features and the consequences of non operating, follow standardized protocols, use products and materials tested and certified by the most influential scientific literature, be care of post-operating effects and adopt all remedies and treatments that can eliminate or reduce post-operating risks, use the best and up-to-date techniques available. In any case he is not liable for unforeseeable events, even if they are in a causative relationship with surgical activity

Every surgical act could be considered a criminal offence, were it not for the patient’s consent. The latter formerly used to be considered implicit but it now has to be made explicit, which may include signing an informed consent document. In case of litigation, the surgeon may be required to provide evidence that the patient received full information and was in a position to give informed consent. Every adult individual is supposedly able to understand and to recall technical information on any specific operation; we know how unrealistic this is. The information should be complete, including on complications least likely to occur; it should also be made understandable to the patient. Assuming this would be possible, the surgeon may be requested later on to provide evidence that such information was provided. How to prove this remains an unsolved problem. A stereotyped informed consent document will be no obstacle to a determined lawyer. Unless every patient receives a customised information booklet written with assistance from a lawyer, the surgeon will always have difficulties in providing evidence that the patient was fully informed. Litigation will often end up with patient and surgeon presenting two irreconcilable versions. One of the reasons is poor retention of information by the patient. A number of studies all showed that retention of basic information is poor and falls down to 50 % after one week and 18 % after 6 months; besides, any “unpleasant” information will be selectively forgotten. In countries that do not have a no-fault compensation system, the only way for some patients to obtain compensation for a disability or financial harm following surgery is to sue the surgeon for malpractice. Lawyers have found out that it was easier to plead the absence of informed consent. We have no real possibility to prevent this, and the quest for absolute security would be hopeless and would result in a paranoid behaviour on the part of the surgeons. Judiciary insecurity has become part of our everyday life and we must cope with it; no-fault compensation systems may improve this but only to some extent. It is best to treat only patients with whom a confident relationship appears possible, as we know that they will usually not quite understand what is going on and will anyway forget most of the information provided

Purpose: Wrong sided surgery is a devastating, yet avoidable adverse event. The Committee on Orthopaedic Practice & Economics (COPE) position paper on wrong sided surgery in Orthopaedics in 1994 had proposed to develop a reproducible method of operating on the correct side and to educate the orthopaedic community about the standardized procedure and accept this as the standard of care. An update to the COA Membership on success of the position paper was published in the COA Bulletin in 2002. Correspondence from the Canadian Medical Protective Association (CMPA) had demonstrated that there were some encouraging results. There had been a reduction from approximately 13 cases per year in 1987 to five cases per year in 2000. The most common anatomical site involved the incorrect knee. Now 10 years after its acceptance as the standard of care in Canada for orthopaedic surgeons at the COA Meeting in 1995, have all cases of wrong sided surgery been eliminated?. Methods: A search of the CMPA files of malpractice claims as well as cases that were labeled as threats occurring between January 2001 and September 2005 naming a physician and involving the issue of wrong sided surgery were performed. Results: A review of the synopses found 26 cases where wrong site surgery was the central issue. There were 9 cases in 2001, 10 in 2002, 3 in 2003, 3 in 2004 and 1 in 2005. The 26 cases were reviewed in detail and some of the general characteristics were identified. Of those 26 cases, 10 involved the incorrect knee; in 9 cases, an arthroscopy was performed on the wrong knee; in one case, a total knee replacement was performed on the wrong knee. Hand and foot cases usually involved the wrong finger or toe. Conclusions: Despite the position paper from the COA (OPERATE THROUGH YOUR INITIALS), operating room policies, heightened awareness, information and educational sessions at all levels of training, wrong site surgery continues to recur. Review of the files for risks have identified the following trends: patients had been anesthetized, the extremity prepared and draped without the surgeon seeing the patient first, the surgical area had been marked by a person other than the surgeon, the medical record and/or radiographs were not available in the operating room, and the hospital policy was not followed. Surgeons need to be mindful that wrong sided surgery has not been eliminated, and educate their surgical team in its prevention

Aims

Time to treatment initiation (TTI) is generally defined as the time from the histological diagnosis of malignancy to the initiation of first definitive treatment. There is no consensus on the impact of TTI on the overall survival in patients with a soft-tissue sarcoma. The purpose of this study was to determine if an increased TTI is associated with overall survival in patients with a soft-tissue sarcoma, and to identify the factors associated with a prolonged TTI.

Many hospitals do not have a structured process of consent, the attainment of which can often be rather ‘last-minute’ and somewhat chaotic. This is a surprising state of affairs as spinal surgery is a high-risk surgical specialty with potential for expensive litigation claims. More recently, the Montgomery ruling by the United Kingdom Supreme Court has placed the subject of informed consent into the spotlight.

There is a paucity of practical guidance on how a consent process can be achieved in a busy clinical setting. The British Association of Spinal Surgeons (BASS) has convened a working party to address this need. To our knowledge this is the first example of a national professional body, representing a single surgical specialty, taking such a fundamental initiative.

In a hard-pressed clinical environment, the ability to achieve admission reliably on the day of surgery, in patients at ease with their situation and with little likelihood of late cancellation, will be of great benefit. It will reduce litigation and improve the patient experience.

Cite this article: Bone Joint J 2016;98-B:1427–30.

Our aim in this paper was to investigate the guidelines and laws governing informed consent in the English-speaking world. We noted a recent divergence from medical paternalism within the United Kingdom, highlighted by the Montgomery v Lanarkshire Health Board ruling of 2015. We investigated the situation in the United Kingdom, Australia, New Zealand, Canada, and the United States of America. We read the national guidance regarding obtaining consent for surgical intervention for each country. We used the references from this guidance to identify the laws that helped inform the guidance, and reviewed the court documents for each case.

There has been a trend towards a more patient-focused approach in consent in each country. Surgeons should be aware of the guidance and legal cases so that they can inform patients fully, and prevent legal problems if outdated practices are followed.

Cite this article: Bone Joint J 2018;100-B:687–92.

The number of clinical negligence claims in the UK is constantly increasing. As a specialty, trauma and orthopaedic surgery has one of the highest numbers of negligence claims.¹ This study analyses NHS Litigation Authority (NHSLA) claims in trauma and orthopaedics between 2004 and 2014.

A formal request was made to the NHSLA under the Freedom of Information Act in order to obtain all data related to claims against orthopaedic surgery. It was found that the number of claims, and percentage of successful claims, has been constantly increasing over this period, with compensation paid of over £349 million.* Errors in clinical management accounted for the highest number of closed claims (2933 claims), costing over £119 million.*

The level of compensation paid out has a significant financial impact on the NHS. Reforms need to be made in order to tackle the high cost of legal fees generated by these claims, which further drain the limited resources available to the NHS.

Nerve palsy is a well-described complication following total hip arthroplasty, but is highly distressing and disabling. A nerve palsy may cause difficulty with the post-operative rehabilitation, and overall mobility of the patient. Nerve palsy may result from compression and tension to the affected nerve(s) during the course of the operation via surgical manipulation and retractor placement, tension from limb lengthening or compression from post-operative hematoma. In the literature, hip dysplasia, lengthening of the leg, the use of an uncemented femoral component, and female gender are associated with a greater risk of nerve palsy. We examined our experience at a high-volume, tertiary care referral centre, and found an overall incidence of 0.3% out of 39 056 primary hip arthroplasties. Risk factors found to be associated with the incidence of nerve palsy at our institution included the presence of spinal stenosis or lumbar disc disease, age younger than 50, and smoking. If a nerve palsy is diagnosed, imaging is mandatory and surgical evacuation or compressive haematomas may be beneficial. As palsies are slow to recover, supportive care such as bracing, therapy, and reassurance are the mainstays of treatment.

Cite this article: Bone Joint J 2017;99-B(1 Supple A):46–9.

The “Universal Protocol” (UP) was launched as a regulatory compliance standard by the Joint Commission on 1st July 1 2004, with the primary intent of reducing the occurrence of wrong-site and wrong-patient surgery. As we’re heading into the tenth year of the UP implementation in the United States, it is time for critical assessment of the protocol’s impact on patient safety related to the incidence of preventable never-events. This article opens the debate on the potential shortcomings and pitfalls of the UP, and provides recommendations on how to circumvent specific inherent vulnerabilities of this widely established patient safety protocol.

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

Interest in football continues to increase, with ever younger age groups participating at a competitive level. Football academies have sprung up under the umbrella of professional clubs in an attempt to nurture and develop such talent in a safe manner. However, increased participation predisposes the immature skeleton to injury. Over a five-year period we have prospectively collected data concerning all injuries presenting to the medical team at Newcastle United football academy. We identified 685 injuries in our cohort of 210 players with a mean age of 13.5 years (9 to 18). The majority of injuries (542;79%) were to the lower limb. A total of 20 surgical procedures were performed. Contact injuries accounted for 31% (210) of all injuries and non-contact for 69% (475).The peaks of injury occurred in early September and March. The 15- and 16-year-old age group appeared most at risk, independent of hours of participation. Strategies to minimise injury may be applicable in both the academy setting and the wider general community.

Payments by the NHS Litigation Authority continue to rise each year, and reflect an increase in successful claims for negligence against NHS Trusts. Information about the reasons for which Trusts are sued in the field of trauma and orthopaedic surgery is scarce.

We analysed 130 consecutive cases of alleged clinical negligence in which the senior author had been requested to act as an expert witness between 2004 and 2006, and received information on the outcome of 97 concluded cases from the relevant solicitors. None of the 97 cases proceeded to a court hearing. Overall, 55% of cases were abandoned by the claimants’ solicitors, and the remaining 45% were settled out of court. The cases were settled for sums ranging from £4500 to £2.7 million, the median settlement being £45 000. The cases that were settled out of court were usually the result of delay in treatment or diagnosis, or because of substandard surgical technique.

Procedures performed at the incorrect anatomical site are commonly perceived as being relatively rare. However, they can be a devastating event for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong-site, wrong-procedure and wrong-patient events occur more commonly than we think. Furthermore, their incidence may be increasing as NHS Trusts increase the volume and complexity of procedures undertaken in order to cope with increasing demands on the system. In previous studies from North America orthopaedic surgery has been found to be the worst-offending specialty.

In this paper we review the existing literature on wrong-site surgery and analyse data from the National Patient Safety Agency and NHS Litigation Authority on 292 cases of wrong-site surgery in England and Wales. Orthopaedic surgery accounted for 87 (29.8%) of these cases. In the year 2006 to 2007, the rate of wrong-site surgery in England and Wales was highest in orthopaedic surgery, in which the estimated rate was 1:105 712 cases.