Broken Drill Bits During Surgical Procedures: A Review of 156 Patient Safety Events

​Christine E. Sanchez (chrsanchez@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority (PSA). She is responsible for utilizing patient safety data, combined with relevant literature, to develop strategies aimed at improving patient safety in Pennsylvania.​

Broken surgical drill bits pose a risk to patient safety. A routine review of event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) uncovered an increase in the number of event reports related to broken drill bits, prompting an exploration to better understand patterns of drill bit breakage in Pennsylvania.

We queried the PA-PSRS database to identify event reports describing a broken drill bit during surgery submitted between January 1, 2021, and December 31, 2023. Event reports were manually coded to identify the procedure, anatomic location of breakage in the patient’s body, timing of discovery, and fragment fate.

A total of 156 relevant event reports were identified. The procedure being performed was determined in 64 of 156 event reports. Fracture repair procedures were most commonly reported to encounter a broken drill bit (27 of 64; 42.2%). We were able to determine the anatomic location in the patient’s body where the drill bit breakage occurred in 108 of 156 event reports. The most commonly reported anatomic location was the femur (27 of 108; 25.0%). We were able to determine the fate of the broken drill bit in 141 of 156 event reports, and most drill bits were retained in the patient (99 of 141; 70.2%).

This data analysis provides insight into broken drill bits in Pennsylvania facilities. Because drill bits are commonly broken pieces of equipment and the fragments from these broken pieces are frequently retained, it is important to prevent drill bit breakage to improve patient safety. Table 2 outlines prevention strategies established by equipment manufacturers and previous research. Implementing these strategies can address breakage across multiple procedures and patients.

orthopedic surgery, drill, drill bit, surgery, patient safety