How One Department Drastically Decreased Errors in Instrument Processing

Prevention Challenges

How One Department Drastically Decreased Errors in Instrument Processing

“Surgical instrument processing errors are a barrier to the highest quality and safety in surgical care.”

After a review of error data within sterile processing at UofL Health identified a need for education and process standardization within the department, it developed a novel approach to quality monitoring which helped identify and reduce errors.

Since implementation in 2018, the program has resulted in a reduction of quality errors from an average of 17 per month to three — an 80 percent sustained decrease.

Additionally, immediate use steam sterilization (IUSS) rates decreased from 6 percent to less than 1 percent. That, the authors write, increases patient safety by reducing events that could potentially lead to mortality or infection. The reduction reduces delays in surgical operations, as well. IUSS is defined as the shortest possible time between a sterilized item’s removal from the sterilizer and its aseptic transfer to the sterile field, according to APIC. The Joint Commission states IUSS items should not be stored for later use.

These and other results were presented in a poster at the APIC Annual Conference in June 2022.  

“Surgical instrument processing errors are a barrier to the highest quality and safety in surgical care,” the authors conclude. “However, these are modifiable through educational initiatives, standardization, and targeted resources.”

Hospitals have thousands of instrument sets that are reprocessed millions of times annually, and processing errors can impact operations, post-surgical infection rates and patient safety. Since 2014, more than 10,000 medical device reports have been submitted to the FDA’s MAUDE database describing actual or potential contamination of flexible endoscopes.

Standard operating procedures and standardized training programs “have shown success in reducing errors, leading to better quality outcomes, and improving patient safety,” they add.

The program included an educational plan with weekly in-services, individual training, process standardization and a modified orientation program. It utilized visual, auditory and kinesthetic learning methods. 

New standard operation procedures were implemented to help avoid errors in daily operations. Competency observations were reviewed after 90 days to “ensure fundamentals were retained and to gather overall feedback on the training program.”

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