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Epidemiology and Prevention of Cast Saw InjuriesResults of a Quality Improvement Program at a Single Institution
Benjamin J. Shore, MD, MPH, FRCSC1; Sarah Hutchinson, OTC1; Marie Harris, MPH1; Donald S. Bae, MD1; Leslie A. Kalish, ScD1; William Maxwell, III, OTC1; Peter Waters, MD1
1 Department of Orthopaedic Surgery (B.J.S., M.H., D.S.B., W.M., and P.W.), Main Operating Room (S.H.), and Clinical Research Center (L.A.K.), Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail address for P. Waters: Peter.Waters@childrens.harvard.edu
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Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2014 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2014 Feb 19;96(4):e31 1-8. doi: 10.2106/JBJS.L.01372
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An investigation was conducted to establish the hospital-wide prevalence of cast saw injuries and to identify variables that put patients at increased risk, with the goal of reducing the injury rate.


Information was collected from January 2010 through December 2012 on all patients who had a cast removed or cut at our institution. Locations included the operating suites, emergency department, ambulatory clinics, and hospital floors. A cast cutting log was used to capture the total number of casts cut. An adverse event form was used to document each injury. A continuous quality improvement approach was used throughout the study period to implement incremental improvements to our program. Changes included an education and certification program on cast saw use for all providers, a protocol for a plastic surgery consultation, and a cast saw blade inspection protocol with maintenance logs.


Twenty-nine injuries occurred in 23,615 cast cuttings over the three years, for an overall rate of 1.23 (95% confidence interval [CI], 0.86 to 1.76) per 1000. A minor decrease in cast saw injuries was recorded over the course of the study (eleven of 8043 [1.37 per 1000] in 2010, ten of 7885 [1.27 per 1000] in 2011, and eight of 7687 [1.04 per 1000] in 2012), but the decrease was not significant (p = 0.87). The emergency department had the highest rate of cast saw injuries (p < 0.0001), with a significantly greater rate during the night compared with the day (eleven of 1293 [8.51 per 1000] compared with fifteen of 19,419 [0.77 per 1000], respectively; p < 0.0001). The injuries were all minor. Key risk factors for a cast saw injury included provider inexperience, patient sedation, and poor cast saw blade condition.


The rate of cast saw injuries in a busy pediatric orthopaedic department was small, but a considerably increased risk existed for those patients cared for in the emergency department by orthopaedic residents. Improving education and training in cast saw use has the potential to decrease the prevalence of cast saw injuries over time.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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