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Open Book: Incorrect assembly of surgical equipment (June 2016)

16th November, 2021

This report alerts providers to key findings and actions following review of two incidents in different organisations where surgical equipment was assembled incorrectly resulting in patient harm in the operating theatre. The aim is to learn from the findings and recommendations made after the events to prevent future similar events.

We advise providers to consider this report, and whether the changes and recommendations might apply to their own systems.

This report is relevant to:

  • operating theatre staff
  • procurement staff
  • medical device manufacture and sales industry staff
  • quality improvement, clinical risk and patient safety managers.

Last updated: 16th November, 2021