Top 13 Sterile Processing Mistakes in Hospitals

Arthur Trapotsis
Written by: Arthur Trapotsis

MS Biochemical Engineering, MBA, Consultant

When it comes to ensuring patient safety in hospitals and ambulatory surgery centers (ASCs), the Sterile Processing Department (SPD) is among the last lines of defense. It’s this department’s sole responsibility to make sure that reusable instruments and devices are properly decontaminated, sterilized, and ultimately safe to use in future procedures — protecting patients from potential surgical site infections (SSIs) and the transmission of certain viral diseases.

When the stakes are this high, errors can be costly — and not just in dollars. This is why it’s crucial for healthcare facilities to take every measure to prevent mistakes from occurring in their SPDs. Since it’s difficult to avoid making errors if you don’t know what they are, we compiled a list of the 13 most common sterile processing mistakes (along with some tips for how to prevent them) so your facility can take a proactive approach toward promoting patient wellbeing.

Top 13 Sterile Processing Mistakes

One way to limit sterile processing mistakes is to figure out why they occur in the first place. With this knowledge, you can take a proactive approach to error mitigation by making changes to your SPD’s processes, training methods, or environment. In the SPD, mistakes can occur for several reasons, such as:

  • Productivity pressures, such as keeping up with demand
  • A lack of access to manufacturer-provided instructions for machinery use and processing procedures
  • Limited — or a lack of — understanding of the manufacturer’s instructions for processing (where access is available)
  • Insufficient supplies
  • Poor communication between the SPD and the teams they serve
  • Subpar training and lack of certification for SPD staff
  • Focusing on band-aid solutions instead of fixing the root causes of process issues

Some of the most common mistakes that result from these shortcomings include:

  1. Insufficiently training and educating staff on sterilization processes and protocols
  2. Improperly cleaning or decontaminating instruments before sterilization
  3. Using the wrong cleaning procedure or washer cycle
  4. Overloading or misloading the sterilizer
  5. Running the wrong sterilization cycle
  6. Improperly monitoring and documenting sterilization cycles
  7. Using expired or damaged sterilization packaging or sterilization indicators
  8. Failing to properly track and trace instruments throughout the sterilization process
  9. Incorrectly storing and handling sterilized instruments
  10. Performing insufficient maintenance of sterilization equipment
  11. Making incorrect repairs to sterilization equipment
  12. Miscommunication (or lack of communication) between SPDs and other departments within the hospital
  13. Not following standard guidelines and protocols

Dangers of Sterile Processing Mistakes

Just like all mistakes, those made during sterile processing come with consequences. However, since the work of the SPD plays such an important part in maintaining patient safety, even the smallest errors can have significant repercussions for patients and your facility.

An SPD that’s prone to mistakes can open your hospital or ASC up to certain liabilities:

Increased risk of infection

When surgical instruments and other critical devices aren’t properly cleaned, decontaminated, or sterilized before reuse, the chance that they’ll be responsible for causing an infection rises. SSIs, which can occur as a result of contaminated devices, carry a $3.3 billion associated annual cost.

Higher rates of patient mortality

Speaking of infections, hospital-acquired infections (HAIs) — of which SSIs are one variety — have a profound impact on patient mortality rates. According to the CDC, 1 in 17 patients who contract an HAI will die as a result.

Increased wet pack occurrence

Wet packs — a phenomenon that occurs when moisture is present in an autoclave chamber — can occur for many reasons: operator error, component failure, and poor sterilizer maintenance are all common causes. No matter the cause, wet packs can lead to re-contamination issues for your newly sterilized loads.

Delayed surgeries

Surgical delays can occur when communication breaks down between the SPD and the operating room. One of the ways this manifests is in instances of missing or incorrect instruments during operations. Not only does it increase the amount of time patients remain under anesthesia, but it also comes with a price tag: for inpatient cases, the mean cost of OR time is between $36 and $37 per minute.

Reputation damage

An inefficient or inadequate SPD can spell disaster for healthcare facilities. Hospitals and ASCs with high rates of infection — as a result of contaminated equipment or otherwise — suffer from poor patient satisfaction, unfavorable reviews, and often have trouble recruiting top doctors.

Citations and fines

A lack of training for SPD technicians can lead to difficulty meeting industry regulations. When a facility falls short of these standards, they can potentially face loss of accreditation as well as hefty penalties and fines.

How to Avoid Sterile Processing Errors

So how can your healthcare facility avoid making these costly sterilization mistakes? By making operational changes that counteract the conditions where errors are most likely to occur. Ensure that this list of best practices is part of your facility’s sterile processing guidelines

  • Ensure that your SPD is set up for success (i.e. providing sufficient space and the right tools and equipment to excel)
  • Increase your sterilization technician training efforts by offering opportunities for continuing education and conducting regular performance reviews
  • Implement a process monitoring system
  • Develop and maintain a device tech data library
  • Implement an instrument tracking system to ensure sterilization for each instrument set processed
  • Follow industry best practices, such as AAMI sterile processing standards set forth by the Association for the Advancement of Medical Instrumentation

Is Your Healthcare Facility on the Right Track?

Thanks to its low learning curve, steam sterilization technology plays a crucial role in reducing sterile processing errors and ensuring patient safety. Ready to put your ASC sterilization setup to the test? Take our free self-assessment to see whether your current setup sufficiently meets your needs.

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