028 Audit of unexplained fractures in children whilst in hospital care

An empirical observation was made by the nursing staff of four children having unexplained fractures whilst inpatients in a specialist tertiary level paediatric hospital of 389 inpatient beds. These individual cases were each investigated using root cause analysis methodology. Consequently, an audit was undertaken to establish the true incidence of unexplained fractures occurring during inpatient care and to identify any trends and learning. A retrospective search of the radiology information system (RIS) for the period November 2014 to November 2017 was performed using the terms ‘fracture’, ‘fractures’ and ‘fractured’. This yielded 6760 radiology reports relating to 2476 unique patients. Each report was reviewed by a senior radiologist to exclude patients with the following: known/explained fractures, adequate history of trauma, specific bone conditions (e.g. osteogenesis imperfecta), vertebral collapse fractures, fractures occurring out of the hospital. Twenty four individual patients were identified with potentially unexplained fractures related to an inpatient admission. Electronic patient records for the 24 patients were reviewed by a senior radiologist in conjunction with the hospital clinical audit manager. None of the 24 identified patients had fractures raising the concern of undetected non-accidental injury or maltreatment. The most common underlying causes for fractures were extreme prematurity, severe osteopenia, metabolic bone disease, intensive care spell. All four index cases were captured through this methodology providing assurance that similar cases would have been captured. No fractures occurred in the hospital due to excessive handling or maltreatment, and patients with fractures all had strong underlying predisposing factors. Learning points: staff should be aware of the increased risk of fractures in patients with the conditions above. Consideration should be given to a policy of reporting all fractures within an electronic patient record to highlight trends or specific high-risk situations.