Misapplication of spinal collars resulting in harm from unsecured spinal injury

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, the National Patient Safety Team identified  issues around the misapplication of spinal collars.

Hard cervical collars are used following neck trauma or neck surgery to limit movement of the head and neck preventing injury to the spinal cord. The team reviewed an incident where a patient with a dislocated cervical vertebra developed a spinal cord injury. The patient had been in a hard 2-piece (front and back) spinal collar, but the back of the collar had been put on upside down.

A review of the NRLS over a 2-year period found 108 related incidents, where most commonly the back section of the collar was upside down. The team identified that the design of these collars vary; some have directional arrows to ensure correct fitting, but not all, and the visibility of these directional arrows can vary.

Findings were shared with the MHRA who agreed to write to manufacturers to ask them to improve the design to reduce the risk of incorrect placement.  One manufacturer has subsequently updated their instructions for use and issued an accompanying Field Safety Notice to make healthcare providers aware.

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.

A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. 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.