322 Snapshot Re-Audit of Implant Checks in SWLEOC Theatres

Introduction Never events represent a huge cost burden to the NHS due to litigation. One such event occurred at a high-volume orthopaedic unit involving the wrong implant being inserted into a patient. An extensive investigation was undertaken which highlighted a combination of human error in the implant checking process and implant storage system. As a result, local guidance was developed to ensure a ‘prosthetic pause’ was performed prior to implant opening. Method An audit of implant checking practices was performed. The first cycle involved 14 cases observed over two weeks and the second involved 16 cases over five weeks. The checks were deemed compliant if the operating surgeon read aloud the implant details to the team, the scrub nurse did the same and both happened prior to implants being opened. Results The initial audit had 8 of 14 cases complying with local guidance. Following the addition of laminated copies of the guidance to all theatres, the guidance being re-distributed to staff and targeted education of the scrub team this improved to 13 of 16 cases. Conclusions Targeted interventions and the introduction of a ‘prosthetic pause’ resulted in an improvement in compliance with implant checks and reduces the risk of further never events.