HSIB report: Implantation of wrong prostheses during joint replacement surgery (June 2018)

Summary

This report is the Healthcare Safety Investigation Branch (HSIB) first complete investigation which relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event. A never event is a serious incident that is entirely preventable.

Content

The patient was a 62-year-old man who underwent hip replacement surgery. During his surgery, incompatible prostheses made by different manufacturers were used. The error was identified when data from the procedure was recorded in the National Joint Registry several days later.  

The investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again. 

The investigation focuses on hip replacement surgery but the findings are applicable to all orthopaedic joint replacements.