OR Manager - April 2019 - 14

Patient safety
'Coming clean' in the SPD requires collaboration and
competency-Part 1
C
ontaminated surgical instruments
made ECRI Institute's
2019 annual top 10 list of
health technology hazards, coming in at
number five: " Mishandling flexible endoscopes
after disinfection can lead to
patient infections. " Number two on the
list in 2018 was " Endoscope reprocessing
failures continue to expose patients
to infection risk. "
Getting Started
* Process and Work flow
OR Sets up Case
It's not only endoscopes that are of
concern. ECRI Institute's Patient Safety
Organization, which hosts a voluntary
database of events, contained more
than 1,000 events related to the effects
of contaminated instruments between
January 1, 2015, and June 30,
2017. The events fell into one of three
categories: device, surgery/anesthesia,
or healthcare-acquired infections. These
categories are among the Common Formats
from the Agency for Healthcare
Research and Quality, which are used
to promote consistent collection and
analysis of safety data.
A random sample of 536 events related
to contaminated instruments revealed
six types of failure modes:
* immediate use steam sterilization
(IUSS) (60%)
* bioburden or contaminants on instruments
(34%)
* unsterile instruments (34%)
* a vendor instrument issue (16%)
* sterilization quality issues (8%)
* human factors (7%).
Not only do such failures pose a
patient safety threat, they can also expose
healthcare organizations to negative
publicity and possibly litigation. A
recent Google search for " dirty surgical
instruments " produced 601 results, including
reports from local and national
news affiliates.
Part of the problem can be traced to
pressures on the sterile processing department
(SPD). " Surgical volumes are
higher in many areas, with inadequate
instrument availability, increased complexity
of instruments, and not enough
14
OR Manager | April 2019
OR Performs
Case
OR Breaks Down
Case
OR Pre-cleans
Instruments
INSTRUMENT PROCESS AND WORKFLOW
Each step in the process below must be analyzed to ensure high quality.
SPD Sterilization
Instruments into
storage
SPD - Prep and
Pack
SPD
decontaminates
and cleans
Instruments
transported to
SPD
Source: ECRI Institute, Plymouth Meeting, Pennsylvania.
Used with permission.
staff or under-skilled staff, " says Gail
Horvath, MSN, RN, CNOR, CRCST,
senior patient safety analysis IV and
consultant for ECRI Institute, Plymouth
Meeting, Pennsylvania.
When leaders of the OR and SPD collaborate
with each other, their teams,
and other experts, they can reduce instrument
contamination. Part 1 of this
two-part series discusses the scope of
the problem and prevention strategies.
Part 2, which focuses on how to investigate
potential contamination and correct
the situation, also reviews design
and equipment considerations.
Behind the errors
Most people come to work wanting to do
a good job, so why do events such as
contaminated instruments occur? In a
2012 article, Chobin categorized possible
reasons into processes and people.
Process factors
* complex surgical instruments that
are difficult to clean or can't be disassembled
to clean
* ambiguous or missing manufacturer
instructions for use (IFU)
* loaner instrumentation not accompanied
by training for staff on cleaning
and sterilization
* lack of sterile processing input for
instrument and device purchases to
be sure the SPD can meet IFUs
* insufficient inventory that results in
shortcuts and IUSS.
People factors
* insufficient staff
* poorly paid technicians
* high turnover rates
* rushed orientations and training
* no incentives to become certified
* lack of opportunities for staff to adwww.ormanager.com
Cases
picked
and put on case
carts
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OR Manager - April 2019

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