Through its core work to review recorded patient safety events, the National Patient Safety Team identified an incident describing the implantation of out-of-date bone cement products following a joint revision procedure.
It was reported that the incident occurred because labelling did not meet the industry standard, that the outer packaging label should reflect the shortest expiry date of all inner (multiple) products. Our work with the Association for Perioperative Practice (AfPP) and College of Operating Department Practitioners (CODP) indicated that improvements to intraoperative checking procedures could be made and both groups agreed to provide information and guidance to their membership.
We have communicated our concerns regarding the regulatory requirement for individual component labelling to the Medicines and Healthcare products Regulatory Agency (MHRA) and written to the Outcome and Registries Programme that hip cement should be added to the Medical Device Outcomes Registry to improve checking and monitoring practices at point of use and tracking opportunities thereafter. This new registry will collect uniform data on surgical procedures and specified outcomes to improve patient safety and patient outcomes.
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.