Mismatch 'never events' in hip and knee arthroplasty: a cohort and intervention study

• Published in: The bone & joint journal Vol. 101-B; no. 8; pp. 960 - 969
• Main Authors: Odgaard, A, Laursen, M B, Gromov, K, Troelsen, A, Kristensen, P W, Schrøder, H, Madsen, F, Overgaard, S
• Format: Journal Article
• Language: English
• Published: England 01.08.2019
• Subjects: Arthroplasty, Replacement, Hip - instrumentation; Arthroplasty, Replacement, Knee - instrumentation; Cohort Studies; Computer Systems; Denmark; Hip Prosthesis - adverse effects; Humans; Knee Prosthesis - adverse effects; Medical Errors - adverse effects; Medical Errors - prevention & control; Medical Errors - statistics & numerical data; Prosthesis Design - adverse effects; Prosthesis Failure - adverse effects; Prosthesis Failure - etiology; Registries; Denmark; Incompatibility; Knee; Implant; Never event; Patient safety; Arthroplasty; Mismatch; Hip
• ISSN: 2049-4394; 2049-4408
• DOI: 10.1302/0301-620X.101B8.BJJ-2018-1124.R1

The aim of this study was to give estimates of the incidence of component incompatibility in hip and knee arthroplasty and to test the effect of an online, real-time compatibility check. Intraoperative barcode registration of arthroplasty implants was introduced in Denmark in 2013. We developed a compatibility database and, from May 2017, real-time compatibility checking was implemented and became part of the registration. We defined four classes of component incompatibility: A-I, A-II, B-I, and B-II, depending on an assessment of the level of risk to the patient (A/B), and on whether incompatibility was knowingly accepted (I/II). A total of 26 524 arthroplasties were analyzed. From 12 307 procedures that were undertaken before implementation of the compatibility check, 21 class A incompatibilities were identified (real- or high-risk combinations; 0.17%; 95% confidence interval (CI) 0.11 to 0.26). From 5692 hip and 6615 knee procedures prior to implementation of the compatibility check, we found rates of class A-I incompatibility (real- or high-risk combinations unknowingly inserted) of 0.14% (95% CI 0.06 to 0.28) and 0.17% (95% CI 0.08 to 0.30), respectively. From 14 217 procedures after the introduction of compatibility checking (7187 hips and 7030 knees), eight class A incompatibilities (0.06%; 95% CI 0.02 to 0.11) were identified. This difference was statistically significant (p = 0.008). Our data presents validated estimates of the baseline incidence of incompatibility events for hip and knee arthroplasty procedures and shows that a significant reduction in class A incompatibility events is possible using a web-based recording system. Cite this article: 2019;101-B:960-969.