Background Two doctors working on a busy intensive care unit sustained injuries whilst removing a chest drain from an HIV‐positive patient. One doctor had a needlestick injury into his finger whilst the other sustained an eyesplash when the chest drain was pulled out.

Methods Following Department of Health format ‘Doing less harm’, a root cause and human factor analysis of the incident was carried out. The aim was to explore the underlying issues.

Results and conclusions Training, cultural and organizational issues were exposed, and are now being addressed. This approach has led to a far more effective dialogue with the National Health Trust concerned than was previously experienced, and there is early evidence of progress on important aspects of health and safety management at organizational level. Lack of health and safety training of doctors at undergraduate and postgraduate level needs to be addressed.