This site has not been optimised for Internet Explorer due to Microsoft no longer providing support for the browser. Please view this site using another browser such as Google Chrome or Microsoft Edge.
Te Pū rauemi KOWHEORI-19 COVID-19 resource hub

Support for people working in health during the COVID-19 pandemic. Find information about how you can support yourselves and others, including consumers, teams and colleagues which complements and aligns with Ministry of Health resources.

Kia āta kōwhiri Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

Back to previous page

Open Book: Incorrect assembly of surgical equipment (June 2016)

16 Nov 2021

This report alerts providers to key findings and actions following review of two incidents in different organisations where surgical equipment was assembled incorrectly resulting in patient harm in the operating theatre. The aim is to learn from the findings and recommendations made after the events to prevent future similar events.

We advise providers to consider this report, and whether the changes and recommendations might apply to their own systems.

This report is relevant to:

  • operating theatre staff
  • procurement staff
  • medical device manufacture and sales industry staff
  • quality improvement, clinical risk and patient safety managers.

Published: 16 Nov 2021 Modified: 16 Nov 2021