A doctor looks at an X-ray showing a hip replacement.

Implantation of wrong prostheses during joint replacement surgery

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Investigation summary

Our first complete investigation relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event. A never event is a serious incident that is entirely preventable.

The patient was a 62-year-old man who underwent hip replacement surgery. During his surgery, incompatible prostheses made by different manufacturers were used. The error was identified when data from the procedure was recorded in the National Joint Registry several days later.  

Our investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again. 

The investigation focuses on hip replacement surgery but our findings are applicable to all orthopaedic joint replacements.