Mismatch 'never events' in hip and knee arthroplasty: a cohort and intervention study
Research output: Contribution to journal › Journal article › Research › peer-review
AIMS: 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.
MATERIALS AND METHODS: 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).
RESULTS: 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).
CONCLUSION: 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: Bone Joint J 2019;101-B:960-969.
Original language | English |
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Journal | The Bone & Joint Journal |
Volume | 101-B |
Issue number | 8 |
Pages (from-to) | 960-969 |
ISSN | 0301-620X |
DOIs | |
Publication status | Published - 2019 |
- 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, Prosthesis Design/adverse effects, Prosthesis Failure/adverse effects, Registries
Research areas
ID: 236611905