NHS advisers warned that hospitals are repeatedly failing to implement rules that will reduce the risk of fatal infections passed to patients from contaminated surgical instruments.
The report said that surgical teams are not keeping instruments in sets so they can be traced easily. Instead kits are being swapped for operations, they allege.
Dr Gill Morgan, chief executive of the NHS Confederation, said it was vital to see that surgical instruments were not contaminated and if they were care should be taken to ensure that they were cleaned properly before reuse. 'There is currently much debate across health services in Europe about the use of single and multiple-use surgical instruments,' she said.
"Many professionals, including doctors and managers, feel that manufacturers are often overly cautious in their instructions on the use of surgical instruments and are challenging the guidance on single-use instruments," she added.
A Department of Health spokeswoman said that the breach was serious and should be taken care of immediately.