How can we eliminate an 'NHS Never Event' in hip replacement surgery?

Despite increasing morbidity and mortality rates, and creating a significant financial burden on the NHS, the surgical Never Event of Component Size Mismatch in hip replacement surgery has so far received no attention from the... [ view full abstract ]

Despite increasing morbidity and mortality rates, and creating a significant financial burden on the NHS, the surgical Never Event of Component Size Mismatch in hip replacement surgery has so far received no attention from the field of Human Factors and Ergonomics. After investigating this Never Event it was found that multiple system vulnerabilities are present during the intraoperative procedure, many of which could be solved by very simple interventions.