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Monitoring patients with fractured ribs | Signal

Issue date25 March 2011
This Signal is to increase awareness of the risk of secondary complications after rib fracture.

A typical incident reads:

“Patient transferred from MAU with history of a fall and a fractured rib. When patient arrived at ward [appeared very unwell].  When chest x-ray was done this showed a pneumothorax….CT done and patient needed HDU care.”

While fractured ribs have the potential to cause haemothorax or pneumothorax, signs are not always evident at the first x-ray. Fractured ribs can also lead to chest infection or pneumonia as pain affects chest expansion and inhibits effective coughing. Most patients with suspected rib fracture would be discharged from the emergency department with pain relief and advice on symptoms that should result in a further assessment by a doctor. Patients, especially those with co-morbidities or associated injuries, may require admission for observation and pain relief. The early detection of any deterioration is critical in these patients.

All reports made to the National Reporting and Learning System (NRLS) up to September 2010 were searched, and 34 reports of delays in detecting complications from fractured ribs were found, including 13 haemothoracies, 18 pneumothoracies, and three pneumonias.

Underlying causes included:
  • pneumothorax or haemothorax missed as the doctor reviewing the x-ray was focused on checking for other injuries
  • the need for frequent observations was not understood
  • the need to actively manage pain from rib fracture was not well recognise.

Six patients died and seven needed critical care. However, separating harm caused by the original injury from harm caused by delays in identifying complications is difficult, as patients often had significant underlying illness and other associated injuries.

NHS organisations should ensure that all staff responsible for patients with rib fractures have clear guidance on the appropriate placement of patients, the optimum approach to pain relief, the frequency and type of observations required and the actions to be taken should the patient deteriorate.

Further information, including principles on inpatient care and outpatient follow-up can be found in emedicine: rib fracture.

We would like to hear from you - please contact us with your initiatives to reduce risks in these areas.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.