A wrong implant is opened but identified before insertion. No patient harm occurs. What is the most appropriate response?
Near misses reveal latent hazards without the cost of harm. Open reporting, human-factors analysis and feedback can strengthen ordering, storage and checking processes; absence of injury is not absence of risk.
A. Discard the packaging and say nothing: This loses learning and permits recurrence.
B. Discipline the individual who opened it without reviewing the system: A purely punitive response misses contributory factors and suppresses reporting.
C. Record it only if the patient complains: Safety reporting is not complaint-dependent.
D. Tell the patient that an implant was inserted incorrectly: Candour should be factual; the wrong implant was not inserted, though local disclosure policy may still support explaining the near miss.
E. Report and investigate the near miss, then improve the system that allowed it: Near misses reveal latent hazards without the cost of harm. Open reporting, human-factors analysis and feedback can strengthen ordering, storage and checking processes; absence of injury is not absence of risk.
If the wrong implant had been inserted, immediate clinical assessment, candid disclosure and incident management would be required in addition to system learning.
Independent Clinora educational preparation material; not official JCIE content, an accredited programme, clinical advice, or a substitute for current guidance, local policy and specialist judgement.
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