International audienceIn 2005, following seroconversion by hepatitis B virus in a patient who underwent surgery, an investigation was carried out to identify the origin of the contamination. Evidence collected through this investigation strongly suggests a likely nosocomial transmission from a healthcare worker to a patient. An observational workplace practice review disclosed a certain number of malfunctions that could have played a role in the transmission, even if the exact route of transmission could not be established retrospectively. This case report underlines the importance of standard precautions and good practices of care