Metal-on-metal (MoM) hip resurfacing was developed in the 1990s by surgeons in Birmingham, UK, as a surgical solution to the problem of osteoarthritis in younger, more active patients. Early results were promising and the procedure gained in popularity. However, adverse reports of soft-tissue reaction and failure started to appear from 2008 onwards. Surgeons may be asked to write
This short contribution aims to explain how intervertebral disc ‘degeneration’ differs from normal ageing, and to suggest how mechanical loading and constitutional factors interact to cause disc degeneration and prolapse. We suggest that disagreement on these matters in
Mechanical function and failure of intervertebral discs. In a healthy disc, the nucleus pulposus acts like a pressurised fluid which is restrained by tensile stress within the annulus. With increasing age, the nucleus becomes more fibrous, and biochemical changes cause the whole disc to become less elastic, and more yellow in colour. Mechanically, the hydrostatic nucleus shrinks with age, and concentrations of compressive stress appear in the posterior annulus. Experiments on cadaveric spines have shown that healthy discs can prolapse when loaded severely or repetitively in bending and compression, and that internal disruption of the disc probably follows damage to the vertebral endplates. However, mechanical loading is not necessarily harmful to living discs: on the contrary, moderate repetitive loading may lead to disc hypertrophy rather than injury. Disc degeneration. Degeneration represents some mechanical or biological “insult” superimposed on normal ageing. A defining feature of “degeneration” should be structural failure of the annulus or endplate, because all degenerated discs exhibit structural failure whereas many old discs do not. Degeneration creates high stress concentrations within the annulus. Paradoxically, severe degeneration can lead to gross disc narrowing and reduced stresses in the annulus, presumably because it is “stress shielded” by the apophyseal joints. Animal experiments show that disc degeneration always follows mechanical disruption. In some cases, it may possibly precede it. Disc degeneration and back pain. Pain-provocation studies have shown that severe and chronic back pain often originates in the posterior annulus fibrosus, and can be elicited by relatively moderate mechanical pressure. Anatomical studies indicate that the outer annulus is supplied with complex and free nerve endings from the mixed sinuvertebral nerve. MRI and discographic studies show that back pain is closely correlated with structural features of disc degeneration such as radial fissures and prolapse, although age-related changes in composition are clinically irrelevant. The stress-shielding of severely degenerated discs (see above) suggests that discogenic pain may be most closely associated with intermediate stages of degeneration. The localised stress concentrations found in degenerated cadaveric discs have been directly linked to low back pain in living people.
The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines. Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively. Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time. Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK. In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated.
Despite tendencies for Claims against medical practitioners around Australia to fall, litigation continues to be a burden on individual practitioners and the system. Unlike Claims frequency, Claims costs are not falling and indemnity insurance remains a significant practice cost. Data is presented to illustrate some trends in litigation and illustrative cases are also presented to outline some of the difficulties in defending Claims. Particular emphasis on the degree of difficulty is made in respect of Epidural Abscess.
Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant
Acute post-operative urinary retention (POUR) is a recognized complication following lower limb arthroplasty. Its occurrence may have patient and ultimately
Introduction. Appropriate consenting is part of good medical practice and is a
The aim of this study was to investigate the long-term outcome of isolated, displaced Lisfranc injuries requiring operative intervention and identify whether results of treatment are influenced by workers compensation. This retrospective study reviewed all patients who underwent operative intervention for Lisfranc injuries. Patients with concomitant injuries were excluded from further investigation so that the outcome of purely isolated Lisfranc injuries could be assessed. The minimum follow-up was two years and the senior author performed all the operations. Patients were contacted and their employment status recorded. Ordinal regression analysis was performed to identify which factors influenced the outcome. Forty-six patients were studied and 24 had pursued
Purpose: Litigation continues to be a concern in orthopaedic surgery despite suggestions on how to contain liability. The purpose of this study was to characterize orthopaedic litigation in Canada from 1997–2006. Method: This study reviewed all closed claims reported to the Canadian Medical Protective Association (CMPA) for 1997–2006 in which orthopaedic surgeons were named. There were 11,983 closed legal actions involving CMPA members (>
73,000 physicians), and 1,353 involved orthopaedic surgeons. A careful review of closed legal actions is a recognized tool for risk identification, assessment and management. The CMPA identifies any critical incidents within the closed legal files. A critical incident is defined as any omission or commission in the evaluation or management which led to the problem(s) that triggered the legal action. Each closed legal action can have more than one critical incident. Results: Performance, diagnostic and communication issues were the most frequently identified problems. These three areas account for 55% of the critical incidents identified. Performance related issues accounted for 395 critical incidents (29%). Diagnostic issues, including deficient histories and general evaluations, were identified in 281 cases (21%). Communication-related critical incidents included those concerning informed consent. The lack of informed consent was a common allegation, proven in 71 cases. In 439 cases (32%) there was no identifiable critical incident for the orthopaedic surgeon involved. Seventy-eight per cent of patients experienced minor or no disability and 22% experienced major disability or death. Events related to tibia trauma and knee arthroscopy formed the two major categories of claims. Patient care areas of high risk include the operating room and outpatient clinic. Overall, 31% of legal actions against orthopaedic surgeons had outcomes in favour of the plaintiffs, compared with 33% of all CMPA members’ claims. Conclusion: Although the likelihood for an orthopaedic surgeon to be sued in Canada has decreased over the last 10 years, the percentage of legal cases resolved in favour of plaintiffs has remained stable. Performance-related deficiencies, delays in diagnosis, and failures in communication represent areas of high
All skeletally immature patients who presented with a supracondylar fracture between 01/09/2013 and 24/11/2015 (n = 50) were used to compare the current management of supra-condylar fractures of the humerus in children to the standards set by the BOAST 11 guidelines. 8.1% did not have full documentation of their neurovascular assessment. 93.9% underwent surgery within 24 hours of presentation. Average time to theatre for neurovascularly compromised patients was 4 hours 46 minutes. 81.8% were managed with 2 K-wires as recommended. Only 39.4% of the patients had their wires removed within 3 – 4 weeks. Only 6.1% had the recommended 2 mm wires. AO recommends the use of 2mm wires if 2 lateral wires are used whereas the BOAST 11 guideline recommends 2mm wires where possible. The results clearly demonstrate a need for further education and awareness of the BOAST 11 guidelines. Of particular interest is the documentation of patients' neurovascular status for appropriate management and for
In a society whereby the incidence of obesity is increasing and
Aim. Implant-related infections, including peri-prosthetic joint infection (PJI) and infected osteosynthesis, are biofilm-related. Intra-operative diagnosis and pathogen identification is currently considered the diagnostic benchmark; however the presence of bacterial biofilm(s) may have a detrimental effect on pathogen detection with traditional microbiological techniques. Sonication and chemical biofilm debonding have been proposed to overcome, at least partially, this issue, however little is known about their possible economical impact. Aim of this study was to examine direct and indirect hospital costs connected with the routine use of anti-biofilm microbiological techniques applied to hip and knee PJIs. Method. In a first part of the study, the “Turn Around Time (TAT)” and direct costs comparison between a system to find bacteria on removed prosthetic implants. *. , a closed system for intra-operative tissue and implant sampling, transport and anti-biofilm processing, versus sonication has been performed. An additional analysis of the estimated indirect hospital costs, resulting from the diagnostic accuracy of traditional and anti-biofilm microbiological processing has been conducted. Results. Considering an average 5 samples per patient, processed separately with the sonication or pooled together, using the device. *. , the direct costs comparison shows a similar overall average estimated cost per patient when using sonication (€ 400.00) or the system to find bacteria on removed prosthetic implants. *. (€ 391.70). Indirect hospital costs of false positive or negative intra-operative pathogen identification can be estimated as, respectively, € 65,000 and € 90,000, including possible inadequate treatments and/or surgeries and/or need for further hospital stay, risk of infection recurrence/persistence, possible
Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic.Aims
Methods
Two discrete legal factors enable the surgeon to treat an injured patient the fully informed, autonomous consent of the adult patient with capacity via civil law; and the medical exception to the criminal law. This article discusses current concepts in consent in trauma; and also considers the perhaps less well known medical exception to the Offences against the Person Act 1861, which exempts surgeons from criminal liability as long as they provide ‘proper medical treatment’. Cite this article:
1. Two cases of post-traumatic osteolysis of the outer end of the clavicle are reported. 2. The essential features of the lesion are summarised. 3. The possible
We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted.Aims
Methods
Background. The British Orthopaedic Association Standards for Trauma (BOAST) for peripheral nerve injuries. 1. states:. “A careful examination of the peripheral nervous and vascular systems must be performed and clearly recorded for all injuries. This examination must be repeated and recorded after any manipulation or surgery.”. This study investigated whether this standard was met for patients with upper limb trauma at a busy London Accident and Emergency (A&E) Department. Method. Data was gathered prospectively from A&E admission notes for 30 consecutive patients with upper limb injuries from the week beginning 11. th. March 2013. Eligibilty: All patients with upper limb injuries. Results. 30 patients: 18 Males mean age of 39.2 and 12 Females mean age of 40.1. 17 patients (56.6%) had documentation of examination of neurovascular status. 14 patients required manipulation and/or splinting of their injury. Of these, no patients had their neurovascular examination documented after the procedure. Poor adherence to the standard is evident across all grades of doctors: FY2, SHO and SpR. Conclusion. There is clear scope to improve documentation of neurovascular status in upper limb injuries. It is especially important to clearly document neurovascular status following manipulation or splinting from a
1. A measuring instrument is described which enables the surgeon to determine the anteroposterior diameter of the vertebral canal during operation. 2. Developmental narrowness of the lumbar vertebral canal is shown to exist and to be caused by an abnormally short antero-posterior diameter. 3. In patients with a narrow, although not abnormally narrow, lumbar vertebral canal, slight deformities such as posterior spur formation or small disc protrusions may produce particular symptoms, which are interesting from a clinical as well as from a
The results of treatment of Lisfranc injuries are often unsatisfactory. This retrospective study investigated 46 patients with isolated Lisfranc injuries at a minimum of two years after surgery. Thirteen patients had a poor outcome and had to change employment, or were unable to find work as a result of this injury. The presence of a compensation claim (p = 0.02) and a delay in diagnosis of more than six months were associated with a poor outcome (p = 0.01). There was no association between poor functional outcome and age, gender, mechanism of injury or previous occupation. This study may have
The aim of this study was to review the data held with the NHSLA database over the last 10 years for negligence in spine surgery with particular focus on why patients ‘claim’ and what is the likely outcome. Anonymous retrospective review. We contacted the NHSLA and asked them to provide all data held on their database under the search terms ‘spine surgery or spine surgeon.’. An excel sheet was provided, and this was then studied for reason of ‘claim’, whether the claim was open/closed and outcome. A total of 67 claims of negligence were made against spinal surgeries during this time (2000-09). The number of claims had increased over the last few years: 2000-03, n= 8, 2004-06, n= 46. The lumbar spine remains the most common area (Lumbar: 55/67, Thoracic : 6/67, Cervical 6/67). Documented reasons for claims were post-operative complications (n= 28; 42%), delayed/failure to diagnose (n=24; 36%), discontent with preoperative assessment including consent (n=2; 3%), intra-operative complications (n= 10; 15%) and anaesthesia complication (n=3; 4%). Twenty were closed and 47 remained open. The number of successful claims was 8/20 (40%). The mean compensation paid out was £33,409 (range was £820.5 to £60,693). The number of claims brought against spinal surgeries is on the increase, with the most common area being the lumbar spine which perhaps is not surprising as this is the most common area of spinal surgery. Common reasons are post-operative complications and delay/failure to diagnose. The ‘success’ of these claims over the last 10 years was 8/20 (40%) with mean compensation paid out was £33,409. Ethics approval: None;. Interest Statement: The lead author is the CEO and founder of a Personal Injury/
The aim of this paper is to stress that an expert providing
The rate of litigation following personal injury is rising at an exponential rate with no concomitant rise in the actual incidence of these injuries. It is recognised that physical injury can lead to mental health disturbance and such mental health disturbance can delay recovery following injury. No previous study has assessed the incidence of pre-existing mental health morbidity amongst personal injury claimants. The general practitioners records of 750 consecutive personal injury claimants were examined. Mental health diagnoses prior to the index injury were noted and classified using the Diagnostic and Statistical Manual of the American Association of psychiatry. Any treatment by mental health professionals was noted. A highly significant excess of pre-injury psychiatric morbidity was identified in the study population. There was a 40% incidence of at least one mental health diagnosis. There was a highly significant excess of depression and anxiety. 10% of the study group had received treatment from at least one mental health professional. Pre-existing psychiatric morbidity appears to be an independent predictive factor for pursuing litigation following personal injury. In light of existing knowledge that such psychiatric morbidity often results in prolongation of physical symptoms and poor response to standard treatment regimes, it is important to recognise such patients when providing a prognosis in a
The purpose of the study was to determine the percentage of knowledge retained immediately following an outpatient consultation for total hip and knee joint arthroplasty, and whether any improvement in that knowledge occurred after reading an information leaflet about the operation. Patients who were placed on the waiting list for joint replacement surgery, were verbally given information during the consultation about basic operative details, post-operative programme, and potential complications. A questionnaire was completed asking them to recall these details. Information leaflets were then given to them to read. 6 weeks later they were again contacted and asked the same questions. Immediately following a consultation, patients recall only a small percentage of information. In particular, retention of post-operative recovery time frames (51–63%), and possible operative complications (0–61 %). Despite an information booklet, their level of knowledge deteriorates from the initial consultation. Verbal and written information supplied to a patient, may be understood, but it is easily and quickly forgotten. In an increasingly
Aim. To compare spinal outcome measures between patients reviewed for
Introduction and Aims: Lower back and/or leg pain is a symptom of a number of pathological conditions involving lumbosacral nerve roots. Disc herniation is one of the most common causes of LBP (after mechanical back pain). There is controversy regarding the progression of disc degeneration and/or lower back pain to symptomatic disc prolapse over time. Method: The aim of the study was to determine the natural progression of patients with lower back pain/disc degeneration established clinically and on MRI to symptomatic disc herniation over three to six years. Total of 970 patients who had an MRI scan between January 1998 and September 2000 were included in the study. Information about disc pathology, level and number of discs involved were recorded from MRI scan reports. A short questionnaire was sent to all patients. It contained 10 questions regarding current status of pain and neurology, any treatment in form of back injection and operation, current occupation and smoking status. Results: The collected data was analysed using standard statistics software (SPSS). The results will be discussed. Conclusion: The information provided by this study will be useful in judging the natural progression of lower back pain and/or disc degeneration to a symptomatic prolapse intervertebral disc. It will also be useful in
Introduction: Age related histological and radiological changes are widespread in the lumbar spine. The correlation with symptoms is poor and there is good evidence that in later decades the incidence of back symptoms decreases, despite the relentless progression of radiological abnormalities. Much confusion exists regarding Accident Compensation Corporation (ACC) insurance entitlement following injuries in the presence of asymptomatic but existing radiological ageing changes (spondylosis) and existing but asymptomatic spondylolysis/isthmic spondylolisthesis. Aim: To review the relevant literature and ACC Acts to clarify the ACC Act definition of injury/accident and exclusion criteria and the natural history of spondylosis/spondylolysis/spondylolisthesis, in relation to patients sustaining new lumbar spine injuries in the presence of existing but asymptomatic radiological abnormalities. Method: The relevant literature and legislation (1992 ARCI and 1998 AI Acts) were reviewed. Results: Regarding spondylolysis and low grade isthmic spondylolisthesis the literature is conflicting in relation to the incidence of back symptoms. The ACC Acts do not discuss existing disorders or degenerative conditions, but focus on exclusion of cover for ‘personal injury caused wholly or substantially by the ageing process’. Conclusions: As with clinical decision making
Introduction Both congenital and acquired aetiologies for Os Odontoideum have been proposed leading to confusion in a
Whiplash is a contentious issue in the
Introduction: Impingement syndrome has been reported to occur in a proportion of patients (9%) following whiplash injuries to the neck. In this study we aim to examine this finding to establish the association and incidence of subacromial impingement following whiplash injuries to the cervical spine. Method and results: We examined 219 patients who had presented to a single surgeon for a
Introduction A frequently asked
Every country has its own criteria for consent. In most, a written consent form is used to reflect patient understanding and permision for the procedure to happen. While oral consent has as much legal sway as the written consent form, the presence of a signature acts as proof of discussion. All European hospitals should have a 100% compliance with patient’s signing consent forms, but their completion is often incomplete and inaccurate, have errors of omission and have lead to litigation, poor patient understanding and recall. We (along witht the BOA) introduce an computer programme of procedure specific orthopaedic consent forms. They have been created for most common elective and trauma operations. The forms follow the UK Department of Health guidelines on consent and contain a brief explanation of the procedure, offer alternative therapies/consequences of not having the procedure (where appropriate), the serious risks and commonly occurring complications. They are written in layman’s English (aimed at a reading age of 14 years). Preliminary trials have also shown the time taken to print and complete a pre-designed form is much less than that of the current handwritten form, reducing errors of omission whilst still allowing discussion with the patient. The forms are currently available as word documents from an easily navigable website. With a view towards European usage, the forms can be easily translated to other languages at minimal cost. With support from the British Orthopaedic Association (BOA), the BOA
Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centres for their management are initially admitted to DGHs. The referral is made by mailing radiographs with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, financial and
Integrated care pathways (ICPs) have been shown to have many benefits in clinical practice and are being widely adopted in orthopaedic surgery. A high standard of medical record keeping is important for safe patient care and provides information for research, audit and
We hypothesise that patients are unable to recall much of the information imparted during the informed consent procedure. This may have important
During revision hip surgery, damage to the sciatic nerve is due most commonly to excessive tension. While the nerve is strong in tension and is able to tolerate this remarkably, it is sensitive to lateral compression against angled structures and it is likely that tension causes injury by such pressure. In a personal series of 441 revision hip procedures, sciatic nerve injury occurred in 9 recognised cases:. 2 were complete with no useful recovery. 2 were severe with some incomplete recovery. 3 were predominantly lateral popliteal with incomplete recovery. 2 were transient and clinically fully recovered. In only two of these were the cause and the time of injury identifiable. In these cases, pain was not a serious feature but in eight separate
Rising health costs have seen increased emphasis on cost containment. Outpatient follow-up after total joint arthroplasty is one such accumulating cost. Enthusiastic recent media interest in failing implants and unacceptable waiting lists adds further interest to the area. We wished to determine the current post-operative follow-up practices and views of New Zealand Orthopaedic Surgeons. A postal survey was sent to all New Zealand Orthopaedic Surgeons. The response rate was 83% (131/158). There was wide variation in routine practice and beliefs. For cemented THJRs, 13% of surgeons routinely saw their patients for less than one year, 38% followed their patients for less than five years and 53% continued to see patients indefinitely. Follow-up for uncemented/hybrid prostheses was higher: 8% for <
one year, 29% for <
5 years and 59% indefinitely. A system of periodically re-calling patients for x-rays without necessarily seeing them is used by 20% of surgeons. The most frequent reasons given for follow-up were the detection of osteolysis, wear, loosening and patient symptoms. Similar figures for total and uni-compartmental knee replacements were reported. Almost a third of surgeons reported that they were unable to follow-up their patients as they would like to because of resource limitations within the public health sector. 44% believed that future changes in
Routine metalwork removal, in asymptomatic patients, remains a controversial issue in our daily practice. Current literature emphasized the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice. To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal for limb trauma in asymptomatic patients, an analysis of the postal questionnaire replies of 36% (500 out of 1390) of randomly selected UK orthopaedic consultants was performed by two independent observers. 47.4% replies were received. A total of 205 (41%) were found to be suitable for analysis. The most significant results of our study I: 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients. II: 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under, while only 12% of trauma surgeons do routinely remove metalwork in the age group between 16–35 years. III: 87% of the practising surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more. IV: Only 7% of practising trauma surgeons replied to this questionnaire have departmental or unit policy. No policy is needed for metalwork removal, as most of the orthopaedic surgeons were complying with literature guidance supporting the potential risks associated with implant removal, in spite of the limited number of departmental or units’ policies on implant removal and the paucity of the literature documenting the current practice. However, there is a discrepancy among trauma surgeons in relation to metalwork removal between patient age groups. This indicates guidelines would be helpful to guide the surgeon for the best practice. This is important from a
Introduction: This is a prospective study of a series of consecutive cases of Os Odontoideum focussing on CT and MRI data. Both congenital and post-traumatic aetiologies have been proposed in the literature. This can lead to confusion in a
Aim: To identify the incidence of regular medication not being prescribed on initial admission of emergency surgical cases. Material and Method: The data for this audit was taken from all surgical admissions over an approximately one month period between December 2004 and January 2005. Prescribed drugs for each patient were checked the morning after admission. If the patient was unable to provide this information, we obtained their regular medication list from the GP. A total of 71 admissions were studied, 58% were referred from A&
E, whereas 34% from the GP or primary care and a small percentage came from referrals from other wards within the hospital. Results: Out of the 71 admissions, 46 patients were receiving at least one regular medication. Obviously, some patients were on medications for more than one disease and these were looked at individually. From all 71 admissions, 21% of them had at least one error, i.e. at least one regular medication was not prescribed on admission. If there was a documented reason for the omission of a particular drug then this was not counted as an error. Analysing each co morbidity individually, 42% of IHD medication were not prescribed despite being taken on a regular basis by the patient, 33% for hypertensive and diabetic medication, 50% for asthmatic and psychiatric medication and 29% for medication for other less serious conditions. 81% of the errors made were on patients referred from A&
E, while 15% where from patients received from the GP/primary care. Only 4% of the errors was made on patients referred from other wards. However, A&
E referrals were almost double those of GPs. Hence, in a total of 41 A&
E referrals 21 errors were made, while in a total of 24 GP referrals only 4 errors were made. Only 1 error was made in the total of 6 ward referrals. Conclusion and Discussion: The results of this audit are surprising and alarming. 21% of admissions had at least one regular medication not prescribed by the admitting doctors. Missing out on regular medication can have potentially life-threatening effects on patients as well as severe