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Patient Safety Incidents Caused by Poor Quality Surgical Instruments

Research output: Contribution to journalArticle

  • Elizabeth Dominguez
  • Brett Rocos
Original languageEnglish
Article numbere4877
Number of pages6
Issue number6
DateAccepted/In press - 6 Jul 2019
DatePublished (current) - 6 Oct 2019


Objectives: Surgeons require high-quality surgical instruments to carry out successful procedures. Poor quality instruments may break intraoperatively leading to a failed procedure or causing harm to the patient. By examining the National Reporting and Learning Service (NRLS) database, the study aims to define the scale of the problem and provide evidence for the formation of surgical instrument quality control.

Methods: The NRLS was searched from August 2004 - December 2010. The search revealed 2036 incidents, 250 of which were randomly selected and analyzed by a clinical reviewer.

Results: One hundred and sixty-one incidents were identified causing five reoperations, one incident of severe harm, six incidents of moderate harm, 35 of low harm, and 119 no harm incidents. No patient deaths were discovered. Drillbits were the most commonly broken instrument.

Conclusions: This report is likely to only be the tip of the iceberg. Poor reporting of patient safety incidents means that there may be as many as 1500 incidents a year of poor quality surgical instruments causing harm. We suggest that forming a Surgical Instrument Quality Service at Trusts within the National Health Service (NHS) could prevent harm coming to patients, reduce cost, and improve the outcomes of surgical procedures.

    Research areas

  • patient safety, surgical instruments, drillbits, quality, surgery

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    Rights statement: This is the final published version of the article (version of record). It first appeared online via Cueus at Please refer to any applicable terms of use of the publisher.

    Final published version, 334 KB, PDF document

    Licence: CC BY


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