Dear HIFA colleagues,
We have just heard from Deborah van Dyke about the new Global Health Media Project videos on locating and removing non-palpable contraceptive implants. Thank you Deborah for keeping us updated on your excellent work.
I have watched the first of these and the central message is clear: removal should not be attempted unless the precise location of the implant is known, whether by palpation or ultrasound.
I did a quick google search on complications of contraceptive implant removal and found that these are uncommon compared with other surgical procedures but can be serious. Here is a case study and a comment from me below.
==
'A 21-year-old woman presented to our hand and peripheral nerve clinic 4 months after attempted Nexplanon® removal from her left arm. The patient reported that neither she, nor her nurse practitioner (NP), was confidently able to feel the Nexplanon® before the attempted removal. ***Imaging studies to confirm location of the Nexplanon® were not performed*** [my emphasis] The patient remembered a small incision being made at the site of insertion after local anesthetic was injected. The provider was not immediately able to find the Nexplanon®, but after exploring the local area, did grasp another structure in her arm. The patient felt an “electric shock” sensation that radiated down to her medial elbow as the NP pulled. No further attempts to remove the Nexplanon® were undertaken.
'Immediately after the removal attempt, the patient had complete numbness in her small and ring fingers. She returned for follow up to her NP. As months progressed, the numbness did not improve, and she began to notice wasting of her hand muscles and weakness in her grip. At almost 4 months after the attempted removal, her NP ordered a nerve conduction study which showed 50% loss of ulnar nerve function.
'On presentation to the office, she had classic signs of severe, chronic ulnar nerve injury: wasting of the ulnar nerve-innervated intrinsic muscles of the hand, a claw position of the ring and small fingers, and dense numbness in an ulnar sensory nerve distribution (Fig. 1). On examination of her arm, there was a well-healed incision with surrounding scar tissue from the extraction attempt. The Nexplanon® was not palpable. X-rays showed the radio-opaque Nexplanon® at the junction of the proximal and middle thirds of the humeral shaft with the most distal end 16.5 cm proximal to the medial epicondyle.'
'At 7 months after nerve reconstruction, the patient had weak grade 2/5 function of ulnar innervated muscles. She still had dense numbness in an ulnar nerve distribution. She did have an advancing Tinel’s sign on physical exam and reported intermittent paresthesias in an ulnar nerve distribution in her hand.... our case strongly supports the manufacturer’s recommendation that extraction should not be attempted without knowing the exact location of the device...'
==
COMMENT (NPW): We are not told whether the health professional who tried to remove the implant was unaware of the rule never to attempt removal without precise location, or if they 'knew' this but ignored it. It would have been interesting to read the internal case report from a patient safety perspective to assess the determinants of this unsafe care episode.
The case underlines that 'uninformed care is unsafe care'. In a previous message I pointed out that the WHO Global Patient Safety Action Plan appears to ignore this determinant. 'Over two decades, HIFA has consistently highlighted how a failure to meet health workers’ needs, particularly their needs for reliable healthcare information, undermines quality of care and patient safety just as much as technical mistakes do. Over this period, patient-safety thinking has moved from “fix the errors” to “support the people who deliver care.”' I have not been able to read the whole plan in detail, but it seeems to me that the plan seems stuck in information and awareness about patient safety principles rather than clinical knowledge as a determinant of unsafe care.
If other HIFA members accept this point, I would suggest that clinical knowledge as a determinant of unsafe care should be specifically integratedinto the current Global Patient Safety Action Plan. Our current discussion can serve as a starting point.
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org