Table 2 Total observed surgical instrument errors
Error Type | Count of observed errors |
|---|---|
Missing+ | |
Missing instrument | 144 |
Wrong instrument | 9 |
Extra instrument | 7 |
Missing + Total | 160 |
Broken/poorly functioning instrument Total | 44 |
Tray+ | |
Packaging failure | 7 |
Damaged rigid container | 2 |
Failed sterilization | 4 |
Tray + Total | 13 |
Fleet+ | |
Fleet | 6 |
Fleet/turnover | 1 |
Fleet + Total | 7 |
Bioburden+ | |
Possible bioburden/other debris | 4 |
Improperly assembled instrument | 1 |
Bioburden + Total | 5 |
Transport/handling | 7 |
Total | 236 |