Loss of an HLA-matched cornea while recipient was already anaesthetised

Record number: 
985
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Never reported before
Alerting signals, symptoms, evidence of occurrence: 
Just before transplantation the HLA matched cornea accidentally dropped on the non-sterile thumb of an operating theatre team member. Operation was deferred because of risk contamination
Demonstration of imputability or root cause: 
Non sterile handling of cornea
Suggest references: 
AAA