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Purpose

The purpose of this paper is to present a remarkable medical equipment‐induced adverse event and to suggest ways to prevent similar problems.

Design/methodology/approach

This paper uses a case study to discuss when it is necessary to renew medical equipment.

Findings

The paper finds that repairing medical equipment using inappropriate parts causes severe iatrogenic problems.

Research limitations/implications

Events like this may be underestimated because well‐organized reporting strategies in health care units are inappropriate.

Practical implications

Defining expiry dates for medical equipment may prevent unsatisfactory repair, especially when original parts are unavailable.

Originality/value

The paper highlights the fact that simple errors cause severe patient injuries.

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