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.
0 Comments
Recommended Comments
There are no comments to display.
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now