Component Size Mismatch in Total Hip Arthroplasty: Identifying Risk Factors associated with this Surgical Never Event

摘要

This paper presents an evaluation into the causes of the surgical Never Event 'Component Size Mismatch' in total hip arthroplasty. A single-centre prospective service evaluation was conducted at specialist orthopaedic hospital in the UK. Hierarchical Task Analysis and Healthcare Failure Modes and Effects Analysis were used to analyse perioperative procedures and identify potential causes and interventions. Key vulnerabilities in the system included, but were not limited to, poor implant labelling, distractions, communication error, and a difficult working environment. Interventions to reduce this Never Event are proposed and could be tested in simulation environments.