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:
- 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:
- Intraocular implants (IOL)
- Other implants — when implant is known prior to the case
- 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.