10.3 Ethics of Functionality
Key Takeaways
- An instrument that fails a functional test is removed from the set regardless of schedule pressure or the cost of the instrument.
- "It only slips a little" and "the surgeon has never complained" are not acceptable grounds for releasing an instrument.
- Instrument failures during a procedure can cause tissue injury, prolonged operative time, and retained fragments.
- Releasing an instrument with a known defect and warning the OR verbally does not transfer responsibility for the decision.
- Function testing must actually be performed, not recorded as performed, because no downstream check exists.
The Decision
An instrument that fails a functional test — the ratchet springs open, the needle rotates, the scissors drag, the jaws gap, the insulation alarms, the retractor binds — is removed from the set and routed for repair or replacement. No exceptions for schedule, cost, or convenience.
This is an ethics item rather than a technical one because the failures are usually partial. An instrument that is completely broken removes the decision. An instrument that almost works is where judgement — and rationalisation — enters.
The Rationalisations
| Rationalisation | Reality |
|---|---|
| "It only slips a little." | A needle rotating in a wound is a needle rotating in a wound |
| "It holds on the second tooth." | The surgeon will apply it lightly and it will release |
| "The surgeon has never complained." | Surgeons compensate silently and attribute the difficulty to tissue |
| "It's the only one we have." | Then the set is short one instrument, and the OR needs to know |
| "It's expensive." | Cost is a purchasing problem; function is a patient problem |
| "It'll be fine for this case." | You cannot know which case it fails in |
| "I'll flag it for the next repair cycle." | It will be used before then |
| "I'll tell the circulator." | A verbal warning does not make a defective instrument safe |
The last one deserves emphasis. Warning the OR does not transfer responsibility. A defective instrument on a sterile field is available to be picked up, and messages passed at case set-up do not reliably reach the person who reaches for the instrument two hours later.
What Failure Actually Causes
| Failure | Intraoperative consequence |
|---|---|
| Hemostat ratchet releases | Vessel bleeds; blood loss; extra clamping and time |
| Needle holder slips | Needle rotates and bends or breaks; needle handling injury; suture failure |
| Scissors drag | Tissue is torn rather than cut; poor healing; extra time |
| Jaws misaligned | Tissue slips from the clamp repeatedly |
| Grasper tooth bent | Tissue held then released unpredictably; bowel or vessel injury |
| Box lock cracked | Fracture and retained fragment |
| Insulation defect | Stray energy burn outside the field of view, presenting days later |
| Self-retaining retractor binds | Retractor jams open in the wound |
| Powered tool will not stop | Uncontrolled cutting |
| Cutting guide slot worn | Malaligned bone resection and implant |
| Aneurysm clip sprung | Clip slips from the aneurysm neck |
Every one of these is a foreseeable consequence of releasing a partially functional instrument, and the specialist is the only person positioned to prevent it.
Testing Must Actually Be Performed
The functional-testing sections of this guide describe specific physical actions: tap the ratchet, cut the gauze, twist the needle, hold the jaws to the light, sweep the insulation tester, run the handpiece. Under pressure these are exactly the steps that get recorded rather than performed.
There is no downstream check. If the needle-slip test is scanned as done but not done, nobody will ever discover that until the needle rotates.
A related failure is testing until you get the answer you want: closing the ratchet to the third tooth because it will not hold at the first, using two layers of gauze because it will not cut four, or retesting an insulation failure repeatedly hoping for a pass. Changing the test to obtain a pass is falsification of the result.
When the Instrument Cannot Be Replaced
Sometimes there is genuinely no second instrument available. The correct handling is not to release the defective one:
- Remove the failed instrument.
- Document the failure and the resulting gap.
- Communicate to the OR specifically: which instrument, why it was removed, and that the set is short.
- Escalate so the shortage is visible to whoever can resolve it — supervisor, purchasing, or the OR's own inventory.
- Route the instrument for repair rather than leaving it in circulation.
This is a worse outcome than a complete set, and it is a much better outcome than a set that appears complete and contains an instrument that will fail.
The Cost Argument
Removing expensive instruments — a robotic instrument at zero lives, a vascular clamp with worn inserts, a scope with a hazy image — invites resistance on cost grounds. Two responses are worth having ready:
- Many expensive instruments are repairable, not scrap. Gold-handled needle holders, vascular clamp inserts, Fogarty inserts, scopes, and dipped handles are all vendor repairs. Recognising this is the specialist's contribution to cost stewardship.
- The cost comparison is not instrument versus budget. It is instrument versus the cost — clinical and financial — of an intraoperative failure. That comparison is not close.
Working Within Your Competence — and at Its Edge
Functional testing assumes the person performing it knows what a pass looks like, and an honest specialist will sometimes reach an instrument they cannot confidently assess: an unfamiliar loaner device, a calibrated torque handle, a specialty item seen once a year.
The ethical failure here is not ignorance; it is resolving uncertainty in favour of release. An instrument you cannot assess is an instrument of unknown status, and unknown is not the same as acceptable.
The correct actions are to consult the manufacturer's instructions for use, which normally state the functional checks required; to compare against a known-good counterpart in the same set; to ask a colleague or the vendor; and, where the check genuinely cannot be performed in the department, to say so and escalate rather than to sign for it. Departments should support this by making instructions accessible at the bench and by treating a request for help as competence rather than weakness.
The same applies at the limits of your authority. Deciding alone that an out-of-specification device is acceptable is not a decision the assembly bench owns.
Findings That Evaporate at Handover
A large proportion of functional failures are correctly identified and then lost, because the technician who found the problem went home.
The pattern is familiar: an instrument is set aside at the end of a shift with the intention of tagging it properly, a colleague finds it on the bench, assumes it was in the middle of assembly, and returns it to the tray. Nothing was concealed and nobody was dishonest, and a defective instrument is now in a sterile set.
The controls are physical and immediate rather than procedural and later. Tag the instrument at the moment of failure, before doing anything else. Move it physically into the designated repair or quarantine container — not a corner of the bench, not a drawer, not back into the tray. Record it against the set so the count-sheet shortage exists in writing rather than in your memory. Only then continue.
An instrument that is out of the tray, tagged, in the right container, and written down survives a shift change. One that is merely set aside does not.
Peer Situations and How to Handle Them
Occasionally the issue is not your own instrument but a colleague's decision — a set released with a known-defective item, a test recorded but not performed, a shortcut taken under pressure.
Raising it is part of the credential's expectation, and the way to do it that actually works is factual, direct, and immediate: address the instrument and the set, not the person's character, and do it before the tray moves. "This holder failed the slip test — it needs to come out before this goes to the sterilizer" is a workable sentence. If the practice continues or the set has already been released, it goes to the supervisor, because at that point the patient risk outweighs the discomfort.
Departments that punish the person who raises the concern rather than the practice will not hear about the next one.
A needle holder allows slight needle rotation at the first ratchet tooth. It is the only one of its size in the department and the case is in thirty minutes. What is the correct action?
Why does verbally warning the operating room about a defective instrument fail to resolve the ethical problem?
Which practice constitutes falsification of a functional test result?