Broken Drill Bits During Surgical Procedures: A Review of 156 Patient Safety Events
Authors: Sanchez Christine E. 
Published: December 2024

Background 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. Methods 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. Results 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%). Conclusion 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 (251188) outlines prevention strategies established by equipment manufacturers and previous research. Implementing these strategies can address breakage across multiple procedures and patients. Plain Language Summary While a rare occurrence, surgical instruments may break during a procedure. In the case of drill bits, which are one of the most frequently broken surgical instruments, pieces that are left inside of a patient could cause harm, and may migrate to other parts of the body. When Patient Safety Authority researchers noted an increased number of events involving broken and retained drill bits during surgery, they analyzed data from the Pennsylvania Patient Safety Reporting System (PA-PSRS) to help decrease the risk of broken drill bits in surgery. In studying cases involving a drill bit breaking during surgery, researchers learned that most of these events occurred during fracture repair procedures and joint replacement surgery, and drill bits most frequently broke in the femur (thigh bone). In most event reports, the broken drill bit was discovered during the procedure, but in 2.6% of event reports (4 out of 156 reports) it was discovered after the operation. Removing drill bit fragments is recommended; however, surgeons may decide to leave them in place if removal risks damage to the surrounding area, and in many event reports broken drill bits were retained following the surgery with no further intervention. Hospitals and surgical facilities should look to existing literature and device manufacturers’ guidelines for prevention strategies, such as recommended surgical techniques; drill bit sterilization, reprocessing, and storage; and general safety measures, some of which are summarized in the article.