Safety recommendation
The Department of Health and Social Care expands the remit of the working group consisting of Derby Teaching Hospitals NHS Foundation Trust’s Scan4Safety Programme, the National Joint Registry (NJR), and the Medicines & Healthcare products Regulatory Agency to include alerts to identify wrong prostheses prior to implantation.
The Department of Health and Social Care commissions the development and implementation of an interim basic scanning system to identify wrong prostheses prior to implantation.
Response:
DHSC expands the remit of the working group consisting of Derby Teaching Hospital NHS Foundation Trust’s Scan4Safety programme, the National Joint Registry and MHRA, to include alerts to identify wrong prostheses prior to implantation.
The working group consisting of Derby Teaching Hospital NHS Foundation Trust, the National Joint Registry (NJR) and Medicines Healthcare Products and Regulatory Agency (MHRA) has already expanded their scope to include the development of early warning systems to identify wrong prostheses prior to implantation using barcode scanning in conjunction with information from the NJR.
The next Derby/NJR/MHRA working group meeting will take place on 2 October 2018 and a member of the DHSC Scan4Safety team will attend.
DHSC commissions the development of an interim basic scanning system to identify wrong prostheses prior to implantation.
The NJR has advised that it can develop and make available an app utilising the compatibility data it already holds and maintains in its systems. The app would enable the surgical team, prior to undertaking joint replacement surgery, to proactively undertake joint component compatibility verification based on scanning the barcodes already provided by industry on product packaging. In the event of incompatibility, the app would provide an alert. The alert would provide decision support information to the surgeon who would retain the option to select joint replacement components based on clinical need.
There are therefore a number of options on how to respond to take this work forward. The full costs to develop and implement a solution will be determined through further work involving DHSC, NHS Improvement, NHS Digital and the working group consisting of Derby Hospital, the NJR and MHRA. It should be recognised that this approach may provide an interim basic solution, pending a future introduction of a more comprehensive solution to address multiple use cases (such as traceability and costing) across multiple product groups.
In conclusion, NHS Improvement, NHS England, NHS Digital and DHSC will use the outputs from the working group to pilot an initial working solution and work to develop a longer term solution to meet this recommendation.
DHSC will provide periodic updates to HSIB detailing progress to meet all of these recommendations. Please let us know if you have any queries about any of the information provided.
Response received on 18 September 2018.