Mr Hampton had a hip replacement and the wrong prosthetic was implanted, which has been categorised as a "never event" since 2011. The hospital informed HSIB and the incident was selected as the reference incident into a national investigation. The report was published this week. It is available on the HSIB website here.

The report makes recommendations aimed at reducing the risk of incorrect prosthetics being implanted, which are relevant nationally. Even if you don't work in surgery, take a look. Even if you have never had this event happen, take a look. You could get a feel for what might come from this organisation in the future. Who knows, you might come across an incident in your own organisation that might inform national learning in the future and some of the factors identified can equally apply to non-surgical environments or procedures.

In this case, although wrong prosthetics are a "never event", approximately 21 incidents are reported nationally each year.  The majority of incidents reported list "checking procedure not followed" as the root cause. The opportunity to conduct independent investigations into these trends are, in  my opinion, invaluable. However, the work being undertaken by this new organisation (only set up in April 2017) will only be worthwhile if they get buy in to their recommendations.

The recommendations arising out of Mr Hampton's surgery are aimed at NHS Improvement, British Standards Institute, National Joint Registry and Department of Health and Social Care.  Surely this has to be better than "they should have checked the prosthetic was right". 

My take away learning point?

I have been looking forward to see the product of HSIB's work. Their first report reinforces my view that if you look into an incident (even at local level) and you don't find something that could apply wider, keep looking - even if there is proper individual culpability too. Don't stop when you have scratched the surface.

HSIB demands national implant reform in first report