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BMJ Case Rep. 2010; 2010: bcr08.2009.2186.
Published online 2010 May 13. doi:  10.1136/bcr.08.2009.2186
PMCID: PMC3047178
Learning from errors

Caught in the slips

Abstract

We report a case where a patient slipped from the operating table during positioning for a laparoscopic colectomy. This occurred due to failure of the Velcro holding the mattress to the operating table. On further inspection, although the amount of Velcro was satisfactory to hold the patient, it had failed due to a combination of its poor positioning, table design and the build up of ‘fluff’ on the Velcro from the use of incorrect cleaning products. The episode was reported as a critical incident and review lead to the implementation of changes across theatres to prevent such an episode happening again.


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