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Open Book: Surgery abandoned due to unavailable instruments (December 2015)

16th November, 2021

This report alerts providers to the key findings of a recent review and system changes made to prevent the incident happening again. In this case, changes were made to systems relating to loan instruments for specialised procedures.

This report is relevant to:

  • theatre staff and managers
  • sterile supply department staff
  • loan set providers.

Last updated: 16th November, 2021