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Knowledge Hub

Healthcare Safety Investigation Branch report calls for changes to eliminate implant never events

What would improve safety for patients receiving implants?


The Healthcare Safety Investigation Branch’s (HSIB’s) first report has called for a new national scanning system to ensure the correct prosthetics implants before they are put into patients.


The agency was set up in April last year. The report follows an incident in which a patient had two incompatible prostheses implanted during a hip replacement, a mistake that was identified when details of the prostheses were entered into the National Joint Registry.


The HSIB investigations showed that an average 52 wrong implants are installed each year, with the latest figures totalling 65 in the year to March 2018. Implanting the wrong prosthesis is identified as a ‘never event’ by NHS Improvement.


Other recommendations include changes to the NHS Improvement standard for verifying prosthesis and British Standards Institute labels should be made easier to read


HSIB also made the observation that the existing National Reporting and Learning System does not require the inclusion of human factors and environmental conditions. Investigators said a change to include this information would be useful in the future.


After reviewing records, interviewing staff and observing surgical procedures carried out in other settings, the investigators identified fatigue in the case of a nurse who had worked long hours and noise in the operating theatre as factors that could have led to slip in attention.


The organisations responsible for implementing the HSIB report recommendations have 90 days to respond.


Further information

Health Service Journal: HSIB demands national implant reform in first report

HSIB: Chief Investigator’s statement — wrong prosthesis report

NHS Improvement: Never events data