The Role of Non-Technical Errors in Hip Fracture Mortality: A National Retrospective Cohort Study

Hip fracture is a common, high-risk condition over-represented in surgical mortality audits, yet the contribution of non-technical errors has not been examined. This study aimed to determine the number, characteristics and clinical context of non-technical errors associated with patient death in hip fracture mortality to identify targets for improvement.

A retrospective cohort study analysed all inpatient hip fracture mortalities reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2012 and 2019. Patient mortalities flagged with an adverse event or area of concern were independently reviewed using a validated non-technical error classification tool. Outcomes included number and proportion of errors within this cohort, error type, temporal trends, clinical phase of occurrence and team responsibility.

Of 8414 orthopaedic mortalities, 510 were flagged with an adverse event or area of concern, including 255 hip fracture patients. Non-technical errors associated with death were identified in 116/255 (45.5%) patients, with no meaningful change over time. Decision making errors were most common (47.9%), followed by situational awareness (35.2%), communication/teamwork (10.3%) and leadership errors (6.7%). Most errors occurred outside the operating theatre, with 60.6% pre-operative and 28.5% post-operative. Orthopaedics were responsible for 86% of single-team errors and contributed to all multi-team errors. Other specialties were responsible for 14% of single-team errors and contributed to multi-team errors.

In this cohort non-technical errors associated with death are common. Distinct patterns by clinical phase, error type and team involvement highlight actionable targets for interventions to improve surgical safety and reduce future errors associated with death.