Assuring Sterility

  1. Do any of your facilities do any type of sterility/sterilization pause or check prior to the surgery starting? We had a incident where a instrument tray/set got pulled from a sterilizer load and never made it back in.

    Instead, this set made it through CSR unsterile, to the OR unsterile, put away on the shelf unsterile, and then to the OR for a case before it was caught by a ST that it was unsterile.

    Aside from being scary as He&@ :angryfire it was human error which in all reality could happen again.

    We are undergoing some major changes to be sure this doesn't happen again but was seeking out advice, recommendations, etc from others!

    Thank you
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  2. 9 Comments

  3. by   Marie_LPN, RN
    We check everything as we pull it from the cart. We also check as we're opening the stuff, and accepting the stuff.

    The pack gets checked for holes in the dust cover, and in the pack itself.

    If it's wrapped in paper, the non-sterile person picks up the paper and holds it up to the light to check for holes.

    We check to make sure there are integrators and filters in the boxes. We also check and make sure none of the filters are cracked.

    ANYTHING that is even questionable, it's considered unsterile. When in doubt, throw it out.

    CS is responsible for packing and sterilizing things appropriately, but we're responsible for double-checking and the maintenance of the sterility.

    Instead, this set made it through CSR unsterile, to the OR unsterile, put away on the shelf unsterile, and then to the OR for a case before it was caught by a ST that it was unsterile.
    How was it determined that this was unsterile (integrator, holes, no filter)?
  4. by   Marie_LPN, RN
    As for a recommendation, our CS dept. has to initial each package of who did what. Someone has to initial the product for prepping and packing it. The person who puts it in the sterilizer initials it also. This was, it can be traced back, if something's not right about it.

    Example: I took out a rack of hysterectomy instruments on a string to count with the circulator. None of the instruments were strung in order, as it PLAINLY says on the sheet, not to mention 2 retractors were missing, yet ALL of the instruments were checked off on the list as if they were all in the box. As you can imagine, i had to rearrange the string before i could begin to count, since Allises, Kokers, and Heaneys were here, there, and everywhere, causing a delay that was higly preventable.

    The instrument sheet had initials on it, and we were able to call CS and complain about it, and give the initials of who did it.
  5. by   staceyp413
    It was first caught when someone went in for a lunch relief near the end of the case and noticed the integrator/indicator on the bottom of the set that hadn't changed. It was then brought to me and I worked with CSR to track the set, house it came in, load, etc and it was clear that it had not gone through the sterilizer.

    At the time it was noticed/verified the MD was just starting to close. Quite the learning experience for all involved and while I wouldn't wish it on anyone, I think our dept and staff learned a lot..........I know I did!!!
  6. by   Marie_LPN, RN
    Integrators should ALWAYS be checked.

    I can't even imagine NOT paying attention to the integrator when i'm accepting stuff.

    Granted CS bears responsibility, but the person (or persons) in the OR that didn't check the integrator is VERY responsible.

    Just like, on the floors, if pharmacy sends the wrong meds, and the nurse gives it anyway. While the pharmacy is at fault for sending the wrong med, the person giving the med is at fault for not double-checking.
  7. by   SFCardiacRN
    Major screw up all around. Sterility of instruments HAS to be assured before transfer to the backtable. That is what external indicators are for. Who opened the instruments? Paper wrapped get autoclave tape and hard cases have plastic pop-locks. The scrub is also supposed to check the internal indicator. Time for a unit wide in-service and QI needs to be instituted for this is truly malpractice.
  8. by   staceyp413
    Already done!!!

    The awful part is that it happened to a ST who is very good at her job and is not one that I'd ever imagine it happening to. We've used it as a learning tool (although a crappy way for it to come about) and already have had a change in practice that we are now collecting all tags, integrators, etc and before the start of the case there is a sterility pause and initials/comments on the OR record.
  9. by   SFCardiacRN
    Very good! That is what QI is for and why mistakes should never be hidden. We are human and we all make mistakes. Reporting leads to practice changes and better care for our patients. I'm sure the patient in question will be monitored closely for infection and will be treated aggressively PRN. I am also using this story at my units next weekly inservice to re-enforce our practice. Thanks!!
  10. by   FST66E
    We had a similar problem at my hospital (thankfully before I started working there). A pan of instruments that was supposedly sterile was opened and used and apparently the tech and RN didn't notice the indicators hadn't changed.

    We now have to chart that the indicators in all sets have changed and "all parameters for sterility have been met". I have a little trouble with charting that the sets are sterile based solely upon indicator color. Even the indicators that are time sensitive aren't all that reassuring to me. I'm being put into the position of guaranteeing someone else's work and I feel that the hospital wants to absolve themselves of responsibility by having the RN sign off on sterility.

    I know that in a lawsuit the lawyers will still go for the deepest pocked but I hope I never have to be in that position.
  11. by   SFCardiacRN
    FST is correct that indicators don't guarantee sterility. They only prove exposure to heat. Just put one on your dashboard and it will turn black. We still have to depend on SPD that all parameters have been met in the sterilization process.

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