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Publication Type: Alert
Single or Multiple Incident: Multiple
Date: 3/22/2017 12:00:00 AM
This alert describes three patient safety incidents where a right implant was incorrectly installed in a left knee. In one case, repair of the implant area was needed for stabilization after the incorrect implant was removed. In the other cases, replacement with the correct implant was non-eventful. Contributing factors are provided as are recommendations to mitigate the likelihood of occurrence of similar incidents.

Additional Details

Device:
knee implants

Rules / Policies / Procedures
  1. Review the standard processes for implant verification and confirm that standard processes are uniformly followed.
  2. Review how component stock is managed, including who can move, remove and replace items. Standardize how separation by laterality is managed.
  3. Identify a proper point in the procedure to definitively verify sidedness of the components. Some organizations may do this during the initial time out by verifying that the only components in the room are for the correct side; not allowing in any other components without a repeat time out. Others may implement this at the time of implant sizing and specific component selection.
  4. Review how vendor representatives are involved in picking the correct component box.
Training
  1. Consider providing memory aids (e.g., pictures) pointing out the locations of the size and side information on the range of devices used in that facility, and showing which devices are sided and which are bilateral.

Correct Knee, Wrong Implant