Adelaide's Women's and Children's Hospital has revealed a lapse in infection control measures during surgery on 13 children.
SA Health says a recent review revealed that antibiotics delivered to the surgical teams were contained in clean, but not sterile, syringes.
The syringes were used to deliver antibiotics into a shunt during cerebrospinal surgery but SA Health says the risk of any harm to the children is extremely low.
The procedure was introduced in 2013 as a way of cutting the rate of infection during such surgery.
"As soon as it was identified that the syringes were not sterile, a new practice was immediately initiated, and a review of other sealed medications coming into surgical theatre revealed this was an isolated incident," SA Health said in a statement on Monday.
"There were no other infection control issues."
The families of the 13 children have been contacted and the hospital will continue to closely monitor their progress.
"The risk of infection arising from this isolated incident is considered to be extremely low, and highly unlikely to lead to any long-term health impact," SA Health said.
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