• E A K van Delft, T Schepers, H J Bonjer, Kerkhoffs G M M J GMMJ Department of Orthopedic surgery, AMC Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands., J C Goslings, and Schep N W L NWL Department of Trauma surgery, Maasstad Hospital, Rotterdam, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands..
• Department of Surgery, VU Medical Center, 7057, Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands. e.vandelft@vumc.nl.
• Arch Orthop Trauma Surg. 2018 Apr 1; 138 (4): 459-462.

BackgroundSafety in the operating room is widely debated. Adverse events during surgery are potentially dangerous for the patient and staff. The incidence of adverse events during orthopedic trauma surgery is unknown. Therefore, we performed a study to quantify the incidence of these adverse events. Primary objective was to determine the incidence of adverse events related to technical equipment and logistics. The secondary objective was to evaluate the consequences of these adverse events.MethodsWe completed a cross-sectional observational study to assess the incidence, consequences and preventability of adverse events related to technical equipment and logistics during orthopedic trauma surgery. During a 10 week period, all orthopedic trauma operations were evaluated by an observer. Six types of procedures were differentiated: osteosynthesis; arthroscopy; removal of hardware; joint replacement; bone grafting and other. Adverse events were divided in six categories: staff dependent factors; patient dependent factors; anaesthesia; imaging equipment; operation room equipment and instruments and implants. Adverse events were defined as any factor affecting the surgical procedure in a negative way.ResultsHundred-fifty operative procedures were included. In 54% of the procedures, at least one adverse event occurred. In total, 147 adverse events occurred, with a range of 1-5 per procedure. Most adverse events occurred during joint replacement procedures. Thirty-seven percent of the incidents concerned defect, incorrect connected or absent instruments. In 36% of the procedures adverse events resulted in a prolonged operation time with a median prolongation of 10.0 min.ConclusionIn more than half of orthopedic trauma surgical procedures adverse events related to technical equipment and logistics occurred, most of them could easily be prevented. These adverse events could endanger the safety of the patient and staff and should therefore be reduced.Level Of Evidence4.

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