24.4 Risk management in acute paediatric orthopaedics
Adverse events in paediatric acute orthopaedics
Non-identification or delayed identification
‘Missed fractures’ are commonly associated with ED litigation, accounting for approximately half of ED negligence claims in the UK and Australia.1 Articles auditing the correlation of ED doctor X-ray analysis with radiologist reporting in recent years show that 1–2% of these reports have a discrepant concordance significant enough to alter management2–6 although in many series there were no long-term adverse events detailed. Fractures can also be missed because of primary assessment failure (failure of thorough history or examination, therefore failure to X-ray). X-rays may be inadequate in coverage or resolution, the abnormality may be missed by the ED physician(s), or by radiologists; this too tends not to show in reported series, which presume radiology reports to be the gold standard, and there may be breakdown between radiologist reporting and ED physician notification and recall of patient. All such oversights have been specifically associated with adverse outcomes7 and the physician responsibility for follow up and communication, which extends to ensuring that a booked follow up does actually occur, must not be overlooked.
Common or serious acute paediatric orthopaedic adverse events are shown in Table 24.4.1.