Background
The malfunctioning of surgical instruments may lead to serious medical accidents.
Limited information is available on the risk of defective instruments. The purpose
of these study is to demonstrate the features of defective surgical instruments, to
establish a strategy to reduce the risk of medical accidents.
Methods
We studied 19,474 consecutive operations during 2007 to 2009 at our hospital. The
data on defective instruments were collected based on the orders for repair of broken
instruments and reports of near-miss incidents. Adverse events caused by defective
instruments were also identified from reports of near-miss incidents.
Results
A total of 1,775 nonfunctioning instruments were identified during the study period.
Of these, 112 were found during operation. More than half of the defective instruments
were tissue-grasping instruments, bone-boring/gnawing instruments, and instruments
for endoscopic surgery. Wearing out and inappropriate use of instruments were 2 major
causes of defects. The rest of the causes consisted of inadequate inspection and factory
defects. Two near-miss incidents (incidence 10 per 100,000 operations) in endoscopic
surgery were potentially critical, but the postoperative course was uneventful in
each patient. The incidence of defects adjusted by the number of operations demonstrated
that bone-boring/gnawing instruments and instruments for endoscopic surgery tend to
be broken during surgery. Without inspection by the manufacturer, the incidence would
be much higher for endoscopic instruments.
Conclusion
Our data suggest that the appropriate use and adequate inspection of particular types
of instruments are key for reducing the risk of medical accidents caused by defective
surgical instruments.
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Article info
Publication history
Published online: September 26, 2011
Accepted:
June 16,
2011
Identification
Copyright
© 2012 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
