About 5,500 patients who suffered fractures are to have their X-rays reviewed after a mix-up at a trust meant some patients were fitted with the wrong metal plates.
NHS Improvement and the British Orthopaedic Association announced the review for all patients who have had surgery involving metal plates for limb fractures since February 2018.
About 140 hospitals providing orthopaedic surgery in England will now review X-rays for patients who received plates for long bone fractures such as the forearm, thigh bone (femur), upper arm bone (humerus), or shin bone (tibia).
The review should be completed by May.
Seven incidents have been reported at a single NHS trust where the wrong type of fracture fixation plate was used.
In one case, a patient fell and the plate buckled, meaning they needed further surgery.
Another a patient needed more surgery after their plate failed when they were having post-operative physiotherapy.
NHS Improvement said recent changes in the designs of some reconstruction plates has meant that two plates, reconstruction plates and dynamic compression plates, are now similar in appearance.
Patients found to be affected at the one trust were not all treated by the same surgeon, suggesting the problem may be more widespread.
It is estimated that 30 to 40 patients at each trust in England could have had a plate fitted – which could amount to more than 5,500 patients needing a review, NHS Improvement said.
Dynamic compression plates, which are used for some fractures, are stronger and more rigid than reconstruction plates.
The latter are more flexible as they may need to be reshaped for use in more complex surgery.
NHS Improvement said that while most fractures heal quickly, it can take up to a year for some fractures.
Therefore, patients whose fractures have not fully healed could be at risk of the plate going wrong if they have had the wrong one inserted.
NHs Improvement national director for patient safety Dr Aidan Fowler said: “When we identify patient safety issues, it is important that we act to reduce the risk of them being repeated.
“We are asking all hospitals in England who provide orthopaedic surgery to review X-rays for their patients who have had surgery involving plates in the past year.
“Patients should not be alarmed and do not need to take any action themselves.
“The risk of harm is low and their local hospital will contact them if there is a chance that they have been affected.”
Any hospital that finds an incorrect plate has been fitted should work with the patient on a care plan, NHS Improvement said.
It should also report the incident to NHS Improvement, carry out a serious incident investigation and change theatre processes to ensure the two types of plate are not confused.
It said NHS hospitals have now been asked to only purchase reconstruction plates that come in individual sterilised packs.