Minnesota Hospital Association

Quality & Patient Safety

May 11, 2012

Implant Verification Alert

Implant Verification

Close to 40% of wrong surgeries/procedures reported under the Minnesota Adverse Event Reporting Law last year (Oct. 7, 2010 -Oct. 6, 2011) were related to wrong implants.

Review of reported wrong procedure events involving implants indicated issues with verification of the correct implant at each step of the process including:

  • Scheduling
  • Requesting the implant(s)
  • Pulling the implant(s) prior to case
  • Team Briefing
  • Pre-procedure verification
  • Time Out
  • Selecting implant(s) from case cart

In January of 2007, a Minnesota Safety Alert was issued related to preventing wrong eye/wrong lens procedures.

The Minnesota Department of Health and Minnesota Hospital Association have reviewed: 1) the root cause analyses from wrong procedure events occurring this past year involving implants; and 2) national and local best practices to develop a set of recommendations for implant verification. The recommendations include verifications steps for:

  1. Intraocular implants (IOL)
  2. Other implants — when implant is known prior to the case
  3. Other implants — when implant is not known prior to the case, e.g. hip or knee replacements.

For more information on this alert, contact Julie Apold, MHA director of patient safety, 651- 641-1121 or toll-free at 800-462-5393 or Rachel Jokela, adverse health event program director, MN Department of Health,  651-201-5807.