“The biggest advances in medicine will not benefit people without our taking the necessary precautions to ensure patient safety,” Prof Pierre Hoffmeyer (Geneva) warned at the 15th EFORT Congress being held in London. There are some alarming examples. Every week, 50 operations are performed in Europe on the wrong part of the patient’s body or on the wrong patients. 15 to 20 percent of postoperative infections could be avoided with better hygiene. In 20 OECD countries analysed, on average five out of every 100,000 hospital files for adult patients involve a foreign object having been forgotten during the surgery in the person operated upon.
“We have seen over the last years the introduction of new materials, new techniques, new medications. Whenever we are facing such new developments in orthopaedics, we need to define the best way of providing innovation to our patients without putting their safety at risk”, EFORT President Prof Manuel Cassiano Neves (Lisbon) noted. “It is essential that we face this topic in a truly multidisciplinary and integrated way.”
Prof Hoffmeyer, Past President of EFORT, noted: “Taking patient safety lightly is like getting in the driver’s seat drunk.” Until recently, patient safety was viewed as a kind of by-product of the art of medical treatment. In the meantime, there is growing awareness: “Patient safety is of central importance for the success of treatment, especially for orthopaedic surgeons. Health care policy-makers are also increasingly discovering patient safety as a key factor for improved and more cost-efficient health care,” Prof Hoffmeyer said. “With this year’s focal point, the Congress seeks to raise awareness about the significance of patient safety and discuss the seemingly mundane things that ultimately decide whether a treatment is a success or a failure. Consistent patient safety programmes help to prevent suffering and costs but they are often more difficult to implement in actual practice than one might assume.”
Complex cultural changes
For instance in the US, experts have advocated for years that patients should be marked with a marker pen a day prior to surgery to be sure the right surgeon operates on the right person and on the right part of the body the next morning. Theoretically it is a very simple idea; practically it requires a change in a complex hospital culture: from the marker pen available always and everywhere and anaesthesiologists who refuse to narcotize non-marked patients to a hospital administration who have to accept that the number of surgeries performed may be fewer under certain circumstances.
Checklists reduce morbidity and the complication rates
Checklist-based procedures should be a matter of course before, during and after surgery according to Prof Hoffmeyer. Most national orthopaedic associations have issued recommendations to this effect but they were slow in being implemented, Prof Hoffmeyer noted, adding: “Many hospitals may have checklists but problems persist with their actual use. To assume everything is taken care of and everyone is sure about what to do is the worst imaginable situation without checks of this kind. My demand is crystal clear: People must always proceed according to a checklist at each operation. This approach would eliminate many avoidable tragedies, for which the surgeons who operate incorrectly or unsuccessfully must ultimately take responsibility.” A large international study revealed that morbidity dropped from 1.5 percent to 0.8 percent following the introduction of checklists. The rate of complications also fell from eleven to seven percent.
Postoperative infections cost as much as ten times more than surgery
The high unnecessary health expenses caused by the lack of patient safety are bringing health care policymakers into the arena. The consequential costs from a post-operative infection can be ten times higher than the surgery itself due to further treatment costs, follow-up surgeries or work disability. The cost of a hip replacement runs an average of EUR 7,300 in Europe but doubles if the hip was incorrectly implanted. The safety of the implants themselves is currently another major issue. Prof Hoffmeyer explained: “The practice for a long time in hip prosthetics was to implant metal-on-metal tribological pairings with large diameters especially in young, active patients due to better stability and a presumed low level of wear. Local metal-associated reactions from soft parts, instances of osteolysis and much increased concentrations of systemic ions have led to a high rate of revision surgery. Various national supervisory authorities and orthopaedic associations have released guidelines for follow-up check-ups and treatment of these types of patients. A working group has since formed at EU level from EFORT experts and is devoted to the issue of how to handle metal-on-metal prostheses.”
The former president of EFORT assumes that politicians and policymakers at European level will soon respond to the urgent problems surrounding patient safety by issuing guidelines or perhaps even statutory provisions. “European associations of medical specialists such as EFORT must actively shape these guidelines by bringing their own expertise to bear. These measures must be practical and evidence-based. We must not allow a sledgehammer to be used to crack a nut.”
Sources: OECD (2012): “Hip and knee replacement” at “Health at a Glance”, OECD Publishing; OECD (2013), “Surgical complications”, in Health at a Glance 2013: OECD indicators, OECD Publishing ; N Engl J Med 2009; 360:491-499January 29, 2009; DOI: 10.1056/NEJMsa0810119; EFORT Congress Symposium Patient Safety, 4 June 2014