Case study: Bone cement implantation syndrome

Through its core work to review recorded patient safety events, the National Patient Safety Team identified reports of harm associated with bone cement implantation syndrome (BCIS).

BCIS is characterised by low oxygen levels, low blood pressure, and cardiac arrest occurring during joint replacement cementation, such as hip and knee surgery. BCIS risks are well known by clinicians, but the reasons and circumstances are not fully understood.

We have raised concerns with the Medicines and Healthcare products Regulatory Agency (MHRA), British Orthopaedic Association, The Hip Society and Safe Anaesthesia Liaison Group regarding the absence of robust data collection on BCIS incidence or outcome, noting the National Hip Fracture Database no longer collects the type of intraoperative data that informed the 2015 BCIS guideline.

We have also recommended to the Outcome and Registries Programme that hip cement should be added to the Medical Device Outcomes Registry. This new registry will collect uniform data on surgical procedures and specified outcomes to improve patient safety and patient outcomes.

In addition, given the need for additional understanding of this topic, it has been included in our National Patient Safety Strategic Research Needs 2022/23.  This document makes visible to researchers and funders the strategic research needs identified by the National Patient Safety Team to encourage further research on key patient safety issues.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.