Never Events

The NHS Healthcare Safety Investigation Branch identified a requirement to reduce the number of ‘Never Events’ associated with joint replacement surgery.  The NJR was identified as a means by which this could be achieved. 

For hip surgery, Never Events are where there is a mis-match in size between the acetabular cup/liner and the head or where different brands of head and stem are used in modular components.  For knees, a Never Event relates to side, e.g. a left-sided component being put into a right knee. 

The data entry system was changed to detect potential Never Events and to warn the data entry user.  At the same time as warning the user, the system generates emails to NJR Centre staff so that they can be investigated.  If an alert is confirmed as a genuine Never Event, the Consultant in Charge is contacted by a surgeon member of the NJR Steering Committee to confirm what action, if any, will be taken. 

A number of Never Events had been confirmed by the end of 2018/19 but the number of ‘false alarms’ was considerably higher.  These alarms were due to mistakes in data entry, such as selecting the wrong side for the operation or using the wrong labels for the implants.  Whether or not the warning has had an impact upon the number of Never Events will be assessed in 2019/20 once there are two years of data to compare.

The only drawback with the warning is that it happens post-operatively, as the procedure data is being entered.  The NJR is working with the Scan4Safety team in the University Hospital of Derby and Burton NHS Foundation Trust to develop a solution that will help to identify potential never events pre-operatively, i.e. before they occur.  This work will continue throughout 2019/20.