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

Manufacturer mismatch does not affect patient outcomes in primary reverse shoulder arthroplasty

BACKGROUND

There is a paucity of literature on manufacturer mismatch in reverse shoulder arthroplasty (RSA). It is unclear if the use of different implant manufacturers for the glenoid side and the humeral side influences patient outcomes in primary RSA. We hypothesize that patients undergoing primary RSA with manufacturer mismatch such that humeral and glenoid components are from different manufacturers will not experience adverse outcomes when compared to a cohort of patients with humeral and glenoid components from the same manufacturer.

METHODS

Between January 2016 and June 2020, all patients who had an RSA implanted by one fellowship-trained shoulder surgeon were considered potentially eligible for inclusion in this retrospective analysis of data prospectively collected during a multicenter study. The inclusion criteria were as follows: primary RSAs implanted through a deltopectoral approach with glenoid and humeral components from different manufacturers, and complete data available at 2 years follow-up. The cohort was divided into a mismatch group and a control group, with the latter comprising patients having undergone RSA with components from the same manufacturer.

RESULTS

From the initial cohort, 191 patients were available for the 2-year clinical and radiological evaluation. Among these individuals were 60 men and 131 women, with a mean age of 74. The mismatch group comprised 39 patients and the control group included 152 patients. Baseline outcome scores of the mismatch and matched cohorts were similar regarding visual analog score (P = .220), Subjective Shoulder Value (P = .518), American Shoulder and Elbow Surgeons (P = .670), and Constant (P = .477) scores. Two-year postoperative outcome scores of the mismatched and matched cohorts were also similar regarding visual analog score (P = .716), Subjective Shoulder Value (P = .125), American Shoulder and Elbow Surgeons (P = .673), and Constant (P = .607) scores. The complication rate and radiological complications were similar.

CONCLUSION

Mixing of glenoid and humeral components from different manufacturers does not appear to affect patient outcomes in primary RSA at 2 years follow-up. The results may provide valuable information for orthopedic surgeons when selecting the appropriate implant components for RSA and help guide clinical decision-making for better patient outcomes. It appears reasonable to have manufacturer mismatch when appropriate matching of implant material and curvature at a given diameter is used.

Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis

BACKGROUND

Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?

METHODS

For this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework.

RESULTS

Our analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as 'wholly preventable'. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy).

CONCLUSIONS

To improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.

[Partial or full component exchange in hip revision? : The relevance of off-label use and mix & match]

Off-label use is frequently practiced in hip revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended (i.e. large bone and soft tissue defects, obesity). Patients may also benefit from selective application of mix & match in hip revision, when the exchange of one component only is necessary and the invasiveness of surgery can be reduced. Currently, there are no formal guidelines for these situations. Therefore, within a recent EFORT initiative, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in revision hip and knee arthroplasty.

EFORT recommendations for off-label use, mix & match and mismatch in hip and knee arthroplasty

Off-label use is frequently practiced in primary and revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended.

Under certain circumstances, patients may benefit from selective application of mix & match. This can refer to primary hip arthroplasty (if evidence suggests that the combination of devices from different manufacturers has superior results) and revision hip or knee arthroplasty (when the exchange of one component only is necessary and the invasiveness of surgery can be reduced).

Within the EFORT ‘Implant and Patient Safety Initiative’, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in primary as well as revision hip and knee arthroplasty.

Prior to the application of a medical device for hip or knee arthroplasty off-label and within a mix & match situation, surgeons should balance the risks and benefits to the patient, obtain informed consent, and document the decision process appropriately.

Nevertheless, it is crucial for surgeons to only combine implants that are compatible. Mismatch of components, where their sizes or connections do not fit, may have catastrophic effects and is a surgical mistake.

Surgeons must be fully aware of the features of the components that they use in off-label indications or during mix & match applications, must be appropriately trained and must audit their results.

Considering the frequent practice of off-label and mix & match as well as the potential medico-legal issues, further research is necessary to obtain more data about the appropriate indications and outcomes for those procedures.

Cite this article: EFORT Open Rev 2021;6:982-1005. DOI: 10.1302/2058-5241.6.210080

Registration and Management of "Never Events" in Swiss Hospitals-The Perspective of Clinical Risk Managers

BACKGROUND

In Switzerland, there is no mandatory reporting of "never events." Little is known about how hospitals in countries with no "never event" policies deal with these incidents in terms of registration and analyses.

OBJECTIVE

The aim of our study was to explore how hospitals outside mandatory "never event" regulations identify, register, and manage "never events" and whether practices are associated with hospital size.

METHODS

Cross-sectional survey data were collected from risk managers of Swiss acute care hospitals.

RESULTS

Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a "never event" has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with "never event" management. Respondents reported that their hospital pays "too little attention" to the recording (46%), the analysis (34%), and the prevention (40%) of "never events." All respondents rated the systematic registration and analysis of "never events" as very (81%) or rather important (19%) for the improvement of patient safety.

CONCLUSIONS

A substantial fraction of Swiss hospitals do not have valid data on the occurrence of "never events" available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for "never events" management.