EMPIRICAL STUDIES doi: 10.1111/j.1471-6712.2009.00760.x Healthcare processes must be improved to reduce the occurrence of orthopaedic adverse events Maria Unbeck RN (Doctoral Student) 1 , Nils Dalen MD, PhD (Professor) 1 , Olav Muren MD, PhD 1 , Ulf Lillkrona MD, PhD (Associate Professor) 1 and Karin Pukk Ha ¨ renstam MD, PhD 2 1 Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics and 2 Karolinska Institutet, Medical Management Centre, Stockholm, Sweden Scand J Caring Sci; 2010; 24; 671–677 Healthcare processes must be improved to reduce the occurrence of orthopaedic adverse events Background: Many nonhealth industries have decades of experiences working with safety systems. Similar systems are also needed in healthcare to improve patient safety. Clinical incident reporting systems in healthcare identify adverse events but seriously underestimate the incidence of adverse events. A wide range of information sources and monitoring techniques are needed to understand and mitigate healthcare risks. Aim: The purpose of this study was to identify patient safety risk factors that can lead to adverse events in adult orthopaedic inpatients. Design: A three-stage structured retrospective patient record review of consecutively admitted patients to the inpatient service of a large, urban Swedish hospital. Method: Records for all orthopaedic inpatients admitted during a 2-month period (n = 395) were screened using 12 criteria. Positive records were then reviewed in two stages by orthopaedic surgeons using a standardized protocol. Data were collected from the index admission and from subsequent visits or readmissions within 28 days of discharge. Results: Sixty patients experienced 65 healthcare associated adverse events. Affected patients had a length of hospital stay double that of patients without adverse events. Adverse events were more common in patients undergo- ing surgical procedures and patients with risk factors for anaesthesia. Although 59 of the adverse events occurred in patients who underwent surgery, only nine of the adverse events were due to deficiencies in surgical/anaesthesia technique. The others were related to deficiencies in healthcare processes. The most common adverse events were hospital acquired infections (n = 20) and delayed detection of urinary retention (n = 13). Six adverse drug events involved elderly patients (‡65 years). Conclusion: Orthopaedic care is a high risk activity for its typically elderly, often debilitated patients. Reducing adverse events in orthopaedic patients will require more multidisciplinary, interdepartmental teamwork strategies that focus on healthcare processes outside the operating room. Keywords: adverse events, orthopaedic care, retrospective record review, patient safety, risk factors, healthcare processes, teamwork, nursing. Submitted 5 January 2009, Accepted 7 October 2009 Introduction Adverse events (AEs) affecting patients are especially common in surgical specialities (1–3). Pukk-Ha ¨ renstam et al. (4) found that surgical specialities accounted for 88% of claims in a large national patient insurance malpractice system, but only 46% of the hospital discharges. Ortho- paedics had one of the highest claim rates. The nature and frequency of AEs differ according to both surgical speciality and by procedure within specialities. Different risks are present in different healthcare settings. A lapse in one speciality or procedure may lead to minor AE, whereas a similar lapse in another can give permanent disability (2, 5, 6). Kable et al. (7) identified risk factors related to five high volumes procedures in surgical care including the orthopaedic procedures hip and knee arthroplasty and suggested criteria for routine monitoring of certain patients undergoing these procedures: age >70 years, type of procedure, duration of operation >2 hour, contaminated surgical site and anaemia. Safety and human factors research in high reliability industries such as major airlines and nuclear power provide knowledge about the occurrence, nature and Correspondence to: Maria Unbeck, Department of Orthopaedics, Danderyd Hospital, SE-182 88 Stockholm, Sweden. E-mail: maria.unbeck@ds.se Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science 671