Patient safety incidents caused by poor quality surgical instruments.
Approach to Improving Safety
Setting of Care
This analysis of the National Reporting and Learning Service database (the United Kingdom's voluntary error reporting system) identified numerous cases of patient harm due to malfunctioning surgical equipment, the most common involving unretrieved device fragments (such as broken drill bits). The authors contend that lack of a standardized reporting and tracking system for surgical instrument malfunctioning poses a potential threat to patients. A WebM&M commentary discussed an incident involving life-threatening hemorrhage due to a broken surgical instrument.