Wrong-size prosthetic implant was accidentally inserted in a patient during surgery

A wrong-size prosthetic implant was accidentally inserted in a patient during surgery and was only discovered during a follow-up appointment four months later, according to NHS reports.

County NHS bosses say that the “never event” – the health service term for preventable serious accidents – was reported in September but the operation took place in May

In a report for the Shropshire, Telford and Wrekin Clinical Commissioning Group governing body, performance, quality and safety chiefs write that “a small prosthesis was implanted instead of a medium-sized one”.

Robert Jones and Agnes Hunt Ortopaedic Hospital Trust Chief Medical Officer Ruth Longfellow said the trust had apologised to the patient. An investigation is ongoing and lessons will be learned, she added.

In a “Quality and Performance Report” covering September and October, CCG Deputy Performance Director David Ashford, Senior Quality Lead Sharon Fletcher and Assistant Director of Quality Tracey Slater write: “There was one never event reported by the trust during September.
“This was a surgical error whereby a small prosthesis was implanted instead of a medium-sized one.
“At the time of writing the investigation is being undertaken by the trust.”

The CCG governing body will discuss the report when it meets on Wednesday, November 10.

RJAH’s latest bimonthly “Integrated Performance Report”, published in late October, says the never event “related to a wrongly-sized prosthesis following an operation that took place in May this year”. Neither it nor the CCG report specifies the type of operation or the location or function of the implant.

Dr Longfellow said: “Incidents of this nature are extremely rare.

“When they do occur, we carry out a full investigation and that is what is happening right now.

“In this case, the patient underwent surgery in May. We became aware of the issue with the size of the implant during follow-up care in September, and immediately made them aware and apologised.

“We take the matter extremely seriously and will use the ongoing investigation to identify learning that will help us to further reduce the likelihood of a repeat in future.”

Diagrams in the IPR show that this is only the third never event to take place at the trust in two years.

The other two both occurred in April 2021. RJAH’s May IPR said one of these “related to a patient given an injection in the wrong hand” while in the second incident an anaesthetic injection was administered to the wrong side of a patient and “immediate remedial actions” were taken after both.