An external review of the sterilisation equipment at Hawkes Bay Hospital has revealed a raft of errors in the sterilisation process.
One of these is that the relevant equipment was never even switched on.
Fifty-five patients are now facing 24 weeks of HIV and hepatitis testing, after they were operated on with unsterilised equipment.
A slew of human and system errors led to the incident, according to the review published on Wednesday.
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"The review has made it clear that no one person or department can be held responsible for this," said executive director provider services Colin Hutchison in a statement.
"There were many errors across a number of systems and processes."
Staff who put the equipment into one of the four sterilising machines on February 1 did not turn the machine on.
The "start" button was known to fail frequently. Once the machine starts, it makes a loud beeping noise.
Staff should always make sure this beep is heard - however, they do not recall hearing this noise.
All sterilising machines (autoclaves) are connected to their own printer which would signal proper sterilisation had occurred.
The printer connected to this particular autoclave had been broken for "some months" according to the review, meaning confirmation was never received.
Instead, staff were supposed to check for confirmation on a computer screen. This did not happen.
The technicians responsible for sterilisation then left for the night, passing responsibility on to the nursing staff who were not trained in sterilising technology.
On February 2, a staff member removed the equipment from the autoclave, failing to check if it was working properly.
This staff member also failed to check the computer to see if the equipment had been sterilised. They also did not check if the sterilisation code had changed colour, which would indicate it had been properly sterilised.
The equipment was then sent to surgery, and the staff taking the equipment from their packs did not check if it was sterilised.
It was not until February 11 that the mistake was realised.
Changes have now been made to ensure this incident will not be repeated.
The printer has been replaced, and the District Health Board will "work towards" appointing an educator specifically for sterile technician training, and a re-training for all staff to ensure all steps and protocols are followed.
Reviewers also recommended there is regular auditing of the process.