Two loose screws: near-miss fall of a morbidly obese patient after an operating room table failure

• Obesity as a risk factor for surgery.
• Falls and near-miss falls in the operating room (OR).
• OR table failure during patient transfer.
• Broken bolt in OR table tilt cylinder bracket.

Operating room surgical table failure is a rare event but can lead to a dangerous situation when it does occur. The dangers can be compounded in the presence of obesity, especially in the anesthetized or sedated patient. We present a case of a near-miss fall of a morbidly obese patient while turning the patient in preparation to transfer from the operating room table to the hospital bed when 2 fractured bolts in the tilt cylinder mechanism led to an operating room table failure.