False Eyelashes Were Found in a Surgical Tray. But That's Not the Most Concerning Part.

False eyelashes.

Rust.

Debris.

All reportedly discovered in a surgical instrument tray opened for a craniotomy at Los Robles Regional Medical Center in California.

According to findings from a California Department of Public Health investigation, the physician declined to wait for a replacement tray and the procedure proceeded.

That's the detail most likely to become the headline.

But surgical professionals need to keep reading.

Because according to the state investigation, this wasn't simply one contaminated tray.

Investigators found contaminated instruments were used in three procedures. Two additional patients had already been placed under anesthesia when their procedures were cancelled because compromised equipment was discovered.

Investigators also identified problems involving reusable instrument cleaning, steam sterilizer maintenance, decontamination areas, adverse-event reporting, surgical services, and hospital oversight.

This isn't just a dirty-instrument story.

It's a systems story.

What Did Investigators Find?

The California Department of Public Health conducted a complaint-validation survey at Los Robles Regional Medical Center after 11 federal complaints alleged the hospital failed to meet Medicare standards.

Investigators substantiated seven complaints.

According to reporting on the state findings, contaminated surgical instruments were used during three procedures.

Two additional patients were reportedly already under anesthesia when their procedures were cancelled because compromised equipment was identified.

One of the three procedures involved a craniotomy.

When the surgical tray was opened, staff reportedly found false eyelashes inside. A separate account cited in the investigation described rust and debris.

According to the state report, the physician declined to wait for another tray and proceeded with the procedure.

But focusing only on that decision risks missing what investigators found elsewhere.

Investigators Looked Upstream

Anyone who works in surgery understands that a sterile tray doesn't magically appear in the operating room.

There is an entire process behind it.

Point-of-use handling.

Transport.

Decontamination.

Cleaning.

Inspection.

Assembly.

Packaging.

Sterilization.

Storage.

Transportation back to the procedural area.

And finally, inspection and use in the OR.

When something is discovered inside a tray, the important question isn't only:

"Who opened this tray?"

We also need to ask:

"What happened before this tray ever reached the room?"

That's where the state findings become especially important.

Investigators reported that reusable surgical instruments were not being properly cleaned.

All three steam sterilizers sampled across the hospital's two campuses reportedly were not being cleaned according to manufacturers' instructions.

Investigators also found decontamination sinks lined with worn and soiled adhesive tape.

Then, during a May inspection, investigators examined five surgical trays.

Four of the five reportedly had issues.

Those findings included white residue, water stains, scratches, and a flaky substance in one tray that was identified as plastic.

At that point, this becomes much harder to describe as one isolated event.

Sterilization Does Not Replace Cleaning

There's an important distinction surgical professionals understand but the public may not:

Cleaning and sterilization are not interchangeable.

Sterile processing is a multistep system.

That is why a breakdown early in the process matters downstream.

And it is why this story should not become an opportunity for the OR to point at sterile processing—or sterile processing to point back at the OR.

These departments depend on each other.

Sterile processing professionals need appropriate equipment, staffing, training, workflows, maintenance, policies, and organizational support to do their work.

OR professionals need to inspect what reaches the field and speak up when something isn't right.

The OR is an important final checkpoint. It should not have to function as the first effective checkpoint.

Two Patients Were Already Under Anesthesia

Another finding deserves attention.

Investigators reported that two additional patients had already been placed under anesthesia when procedures were cancelled because compromised equipment was discovered.

Think about how far the surgical process had progressed at that point.

The patients had arrived.

Preoperative processes had occurred.

The rooms had been prepared.

Teams had assembled.

Anesthesia had begun.

And only then did the equipment issue prevent the procedures from continuing.

This isn't an argument for proceeding once anesthesia has started.

It's the opposite.

It raises an operational question:

How far upstream can we identify a problem before it reaches the patient?

The earlier a safety problem is detected, the more opportunities a team has to respond before the patient is affected by the disruption.

The Investigation Didn't Stop at Sterile Processing

This may be the most important part of the story.

The state didn't frame the findings exclusively as a frontline sterile-processing problem.

Investigators cited deficiencies involving infection control, surgical services, patient safety, and governing-body oversight.

The report also faulted the hospital's board of directors for shortcomings involving policy and oversight.

That distinction matters.

When a safety problem becomes systemic, accountability cannot live exclusively with the person at the bottom of the organizational chart.

Leaders influence:

Staffing.

Equipment.

Maintenance.

Policies.

Training.

Resources.

Reporting structures.

Workplace culture.

And whether frontline concerns actually move upward.

Patient safety is a leadership responsibility too.

What Happens When Someone Speaks Up?

This case also raises an important cultural question.

What happens in your organization when someone says:

"This tray doesn't look right."

Does the team stop?

Does someone investigate?

Does production pressure take over?

Can a surgical technologist speak up?

Can a sterile processing technician escalate a concern?

Can a nurse stop the process?

Can someone question a decision made by a person with more authority?

A policy that says "speak up" is only as strong as the culture surrounding it.

Safety culture becomes real when people can raise concerns without having to calculate the professional consequences first.

Reporting Is Part of Patient Safety

Investigators also determined that the hospital failed to report a related adverse event to California as required.

According to the report, a patient-safety director told investigators the craniotomy event initially wasn't reported because it wasn't considered serious.

That creates another important systems question:

How does an organization decide which safety events deserve escalation?

Reporting isn't only about regulatory compliance.

Safety reports create organizational memory.

They allow patterns to become visible.

They create opportunities to investigate processes before the next event.

If events aren't documented, reviewed, and connected, an organization can repeatedly experience warning signs without recognizing the larger pattern.

What Los Robles Says Has Changed

There is important context here.

These findings came from an investigation completed in May 2026.

Los Robles says it has since worked with the California Department of Public Health and Centers for Medicare & Medicaid Services to address the identified deficiencies.

Hospital spokesperson Megan Merino said CDPH and CMS returned for a validation survey in August and identified "no major deficiencies," and that monitoring of presurgical processes and instrumentation was found to be effective.

The hospital also says it has not been fined or penalized and remains focused on sustaining its improvements.

That matters.

The purpose of discussing an investigation like this shouldn't be to freeze an organization permanently at the moment something went wrong.

It should be to understand what happened, what changed, and what other organizations can learn before experiencing something similar.

Don't Turn This Into OR vs. SPD

There will be a temptation online to make this:

"Look what sterile processing sent upstairs."

Don't.

Surgical safety doesn't work when departments become opponents.

The better question is:

What conditions allow properly cleaned, inspected, sterilized, and functional instrumentation to reliably reach every patient?

And when that process fails:

How quickly does the organization detect it, escalate it, correct it, and learn from it?

That's shared work.

Accountability Without Blame

Accountability still matters.

If policies weren't followed, that matters.

If equipment wasn't maintained, that matters.

If someone raised a concern and it wasn't appropriately addressed, that matters.

If leadership failed to provide adequate oversight, that matters too.

But stopping at:

"Who messed up?"

gives us a name.

It doesn't necessarily give us a safer system.

The questions that create improvement are:

Where did the process first fail?

Which safeguards should have caught it?

Why didn't they?

Were frontline concerns heard?

Were staff given the resources required to follow policy?

Did leadership know there was a problem?

How was the organization monitoring whether corrective actions actually worked?

That's accountability without blame.

Not avoiding responsibility.

Understanding responsibility well enough to prevent recurrence.

The FTLOS Takeaway

False eyelashes inside a craniotomy tray make an unforgettable headline.

But they shouldn't be the only thing we remember.

According to investigators:

Three procedures involved contaminated equipment.

Two additional procedures were cancelled after patients had already been placed under anesthesia.

Four of five trays examined during one inspection had identified issues.

Problems extended into instrument cleaning and sterilizer maintenance.

And the findings reached beyond frontline processing into surgical services, patient safety, reporting, and hospital governance.

That's the lesson.

Patient safety is rarely one person's job.

It's a chain.

And every person—from the decontamination area to the sterile field to the boardroom—is part of it.

Join the Conversation

For OR and sterile-processing professionals:

Where do you think the strongest partnership between the OR and SPD needs to happen—and what makes that partnership work?

Please keep patient, coworker, and facility-identifying information out of the discussion.

FTLOS discusses this case for professional education around healthcare operations, sterile-processing systems, safety culture, and organizational accountability. This article does not provide medical advice or determine individual professional, legal, or organizational liability.

California Hospital Used Contaminated Instruments in 3 Surgeries, State Finds.” Becker’s Hospital Review, 4 Sept. 2026, https://www.beckershospitalreview.com/quality/patient-safety-outcomes/california-hospital-used-contaminated-instruments-in-3-surgeries-state-finds/.