Through its review of recorded patient safety events the National Patient Safety Team identified an issue related to retention of bone cement following hip surgery.
An incident described an elderly patient returning to theatre to remove unintentionally retained bone cement, following a hip replacement procedure for a fractured neck of femur. Bone cement is used to anchor artificial joints (prosthesis) and fills the space between the prosthesis and the patient’s bone. Unintentionally retained cement can result in accelerated implant wear, surrounding tissue or nerve damage, and pain. Often a return to theatre for cement removal is required.
A review of the National Reporting and Learning System (NRLS) identified seven incidents over a two-year period related to retained bone cement following hip surgery. Cement was left predominantly in the acetabulum of the hip joint.
The team contacted the British Orthopaedic Association and British Hip Society to share these findings. Both organisations agreed that whilst this was a rare occurrence it carried significant risk in an elderly and frail patient. It was agreed the existing guidance to perform a sweep of the acetabulum prior to hip reduction and skin closure would be promoted to clinical staff through respective newsletters.
There was also agreement to review the potential to include a ‘pause’ or ‘prompt’ in the Surgical Safety Checklist for such procedures.
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.