DOS 2018

DOS Kongressen 2018 · 103 Mismatch Never Events in Hip and Knee Arthroplasty: A Cohort and Intervention Study Anders Odgaard, Mogens Berg Laursen, Kirill Gromov, Anders Troelsen, Frank Madsen, Overgaard Overgaard Dept. of Orthopaedics, Copenhagen University Hospital Herlev-Gentofte; Dept. of Orthopaedics, Aalborg University Hospital; Dept. of Orthopaedics, Copenhagen University Hospital Hvidovre; Dept. of Orthopaedics, Aarhus University Hospital; Dept. of Orthopaedics, Odense University Hospital Background: Incompatible components in hip or knee arthroplasty may lead to a risk of malfunction and early failure. These mismatch never events are known to happen, but the frequency is largely unknown. Purpose / Aim of Study: We aimed to 1) calculate frequencies of implant in- compatibility in sequentially registered implants and 2) assess whether an online warning system can reduce the frequency of mismatch never events. Materials and Methods: Barcode implant registration was introduced in 11 hospitals from 2013. We developed a compatibility database covering all im- plant families used, and from May 2017, compatibility checking became part of the registration process, immediately warning theatre staff, if incompat- ible implants were registered. Hospitals were contacted to verify every case of recorded mismatch, that had occurred both before and after the introduc- tion of real-time checking. We defined four classes (A-I, A-II, B-I and B-II) of component mismatch depending on an assessment of patient risk (A/B) and on whether the mismatch was knowingly accepted (I/II). Findings / Results: Implants from a total of 22,564 hip or knee arthroplasty procedures were analyzed. Implant information from 12,306 arthroplasty pro- cedures was collected before the introduction of the compatibility checking, and from 5,691 hip and 6,615 knee arthroplasty procedures, we found a class A-I mismatch rate of 0.14% (95% CI: 0.06%-0.28%) and 0.17% (95% CI: 0.08%- 0.30%), respectively. After the introduction of compatibility checking, implants from a total of 10,258 procedures were analyzed, and we identified no class A-I mismatches for hips (p=0.008) or knees (p=0.003). Conclusions: Our data presents validated estimates of the frequency of mis- match never events for hip and knee arthroplasty procedures, and it demon- strates that a significant reduction in class A-I mismatches is possible. Conflict of interest: Anders Odgaard: Stockholder, Procordo Software ApS 44.