An orthopaedic surgeon was operating on a patient and just before a new implant was to be placed, it inadvertently dropped on the floor. The surgeon disinfected the implant by bathing it in iodine twice. The implant was then placed. Later, the implant caused considerable infections in the patient which led to significant damage.

There is no clear and specified procedure for dropped implants. Later it appeared that other doctors would have chosen to have the implant sterilized, however this would have meant that the operation would have to be postponed. The choice for disinfecting the implant was understandable. Nonetheless the surgeon himself was ashamed about the infection and felt embarrassed by it, hence he did not inform the patient that the infection may have been due to inadequate disinfection.