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Implant Mismatch Notification Process


The purpose of the NJR Implant Mismatch Notification Process is to provide clarity and confirmation on the management and notification of potential implant mismatches.

The NJR records and reports on two potential mismatches of components:
  • For hips – a  mismatch in size, for example; between a hip cup or liner and head.
  • For knees – a mismatch in side, for example; a right-sided component recorded as being implanted for a left knee surgery/procedure.

It is important to note that the majority of mismatches are subsequently found to be simply data entry errors. The NJR data entry system enables units to immediately recognise and correct wrongly entered mismatch data entry errors on the NJR system.  As part of the NJR Implant Mismatch Process, an automated pop-up notification is generated, warning the data entry user that the selected choice represents a potential mismatch and that the component selection should be confirmed with the surgeon. 

Never Events

Genuine potential implant mismatches are classified as ‘Never Events’. The Department of Health and Social Care defines ‘Never Events’ as very serious patient safety incidents, which are largely preventable and should not have occured if the relevant preventative measures had been put in place. Where a genuine mismatch has occurred the notification process will assist early implant revision, if this is deemed appropriate.

The chair of the NJR’s Surgeon Performance and Implant Scrutiny Committees, Mr Peter Howard, commented: “Now with over 3 million records, the NJR’s role in monitoring the performance of implants remains of vital importance. Through the robust monitoring processes that are in place, which were enhanced as part of the implementation of the new Model, we can quickly identify if there are potential discrepancies in data relating to hip and knee replacement procedures with the wrong size or side respectively. Identifying potential implant mismatches at the point of data entry demonstrates how the NJR is ensuring even greater patient safety.”




Implant Mismatch Notification documentation:



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