Safety Starts Here: Sterile Processing & Patient Safety

1. Why Should We Be Concerned with Patient Safety?

Patient Safety should be a top priority for every healthcare worker.  A 2019 study by the WHO showed that in high-income countries, an estimated 1 in 10 patients is harmed while receiving hospital care.  Nearly 50% of the adverse events caused were preventable. Industries with a perceived higher risk such as aviation or nuclear industries have a much better safety record than healthcare. One of the things we learn from those industries is that “trying to be safe” and “being careful” are inadequate means of accomplishing a reliable safety record.  Safety requires employees at every level being committed to proven error-prevention techniques and designing safe processes.  This means that every team member in healthcare has a significant part to play in preventing harm to patients: from physicians and pharmacists, to nurses and Sterile Processing technicians.

Ultimately patient safety comes down to keeping the personhood of our patients front and center. They are more than numbers on a chart or surgeries on the schedule. They are mothers, fathers, children, teachers, friends, trauma victims, and scientific miracles. We care about patient safety in Sterile Processing because we care about people.

You can view the WHO article here: https://tinyurl.com/42277sdy

2. What Are Patient Safety Goals?

In 1999, the Institute of Medicine released its pioneering report “To Err Is Human: Building a Safer Health System,” reporting that as many as 98,000 patients died each year from preventable medical errors. Shortly after the report’s release, Congress required the Agency for Healthcare Research and Quality (AHRQ) to issue annual reports that monitor national progress in improving patient care. In the following years, key healthcare organizations implemented initiatives to reduce medical errors. The Joint Commission established the National Patient Safety Goals program in 2002 to identify areas of concern regarding patient safety. The first set of Patient Safety Goals was released in 2003, and they are regularly revised based on their impact, cost, and effectiveness. As an accrediting body, the Joint Commission uses the NPSGs to evaluate the performance of an organization in keeping patients safe.

Aligning your Sterile Processing department’s internal goals, culture, and policy language with these national goals is a great way to signal to accreditation organizations that you are serious about your department’s contributions to surgical safety. Team members from director down to new hire should be aware of and be able to speak to what these goals mean for your department.

For more information on the Joint Commission’s NPSGs, visit www.jointcommission.org

3. Improve the Accuracy of Patient Identification

Patient mis-identification has many implications for healthcare, including administering medications to the wrong patient. For SPD, our primary interaction with patient identification has to do with our role in supporting the surgical schedule.  Many departments pick case carts that are designated for a specific patient, and many loaned surgical instruments are brought to the hospital to be processed and sterilized for a particular patient’s surgery. Incorrect linking of loaned instruments with patients can have a dramatic negative impact on patient care if the loaners are sent to the wrong room and mistakenly opened by the OR staff.  Not only will this cause delays for both procedures involved, this mix up could also lead the hospital to have to emergently re-sterilize the instruments , increasing that patient’s risk for a Surgical Site Infection (SSI).  Does your SPD have robust processes & technological workflows for ensuring instruments are delivered to the correct location at the correct time for the correct patient, or does it rely upon word-of-mouth communication for tracking loaned instrumentation?

4. Improve the Effectiveness of Communication Among Caregivers

The communication loop between the OR and SPD is  lacking at many facilities, and possibly has been broken altogether for a long time.  Particularly during emergency procedures, the Operating Room relies upon Sterile Process for the expedited processing of needed instruments.  Breakdown of communication between these units can lead to delays in reprocessing, delayed care for patients needing emergency surgery, and the further erosion of trust between these two departments.  Your SPD should have clearly defined “cycle times” of how long it takes to process an instrument beginning-to-end to be able to clearly and confidently communicate with the OR during a crisis or even under normal scheduling circumstances.  The organization also needs to have clear parameters set for  where urgent sterilization will be used, and who will be responsible for sterilizing that item.

An important error-prevention technique when communicating verbally or over the phone is to “repeat-back” the information or request to confirm it is correct. This concept should be part of all initial on-boarding for new Sterile Processing technicians and regularly audited to ensure the practice is being implemented on a regular basis.

5. Improve the Safety of Using Medications

While this National Patient Safety Goal can seem completely unrelated to technician’s roles in Sterile Processing, it is not uncommon to see medicine cups and emesis basins come back to decontamination with residual labels and patient stickers still affixed. Why does this occur? What is the purpose behind it in the Operating Room, and why is it so important? According to the Joint Commission Jan 2020 elements of performance section NPSG.03.04.01 – “In perioperative and other procedural settings both on and off the sterile field, labeling occurs when any medication or solution is transferred from the original packaging to another container.” The OR is required to label any container of medication on or off the field.

Also, some Sterile Processing departments may handle medications in the preparation of floor kits or case carts. To reduce errors in these instances, it is best practice to utilize a two-person verification when medications are added to a kit or case cart.

6. Reduce Healthcare Associated Infections

Sterile Processing professionals play a role in the organization’s infection prevention efforts and contribute to the infection prevention process.  The single most effective means of preventing the spread of infection is hand hygiene. SPD technicians should wash their hands:

• Whenever soiled
• Before and after eating
• After using the toilet
• After coughing or sneezing
• After removing gloves

Other dress code considerations must be followed regarding the condition of fingernails, the use of hospital-supplied scrub attire, the use of hospital supplied head and beard covers, the wearing of jewelry, and so on.  Work surfaces can become contaminated by technicians who are not following the hygiene and work attire policies.

SPD professionals must also ensure appropriate PPE is made available to technicians for decontamination.  Equipment should be maintained and monitored to ensure they are functioning according to manufacturers’ guidelines.  Department policies and procedures should be followed by all team members and should be updated to follow clinical best practice and guidelines.

7. Implement Evidence-Based Practices for Preventing Surgical Site Infections

At many facilities, Surgical Site Infections (SSIs) are tracked and reported to the surgery department as an indicator of performance, but SPD is usually left out of that information.  Sterile Processing can make a significant impact on the outcome of a procedure, so they should be educated about surgical site infections, what causes them, and the role they play in preventing them.  Education should occur upon hire, but also annually thereafter.

Infection Prevention guidelines in Sterile Processing include things like the attire policy and hygiene policy, but they also include larger processes like decontamination and inspection.  The biggest risk to the patient from Sterile Processing would be inadequately cleaned or improperly sterilized instruments being used in surgery. The department should have a robust quality monitoring program in place to observe instrument cleaning and sterilization and assure that department policies are being followed in all areas.  Leaders should perform occasional risk assessments to ensure infection prevention policies are being followed consistently.

8. Confronting the Challenge of Bioburden, HAIs, and SSIs

Although hand hygiene is the single most effective means of reducing HAIs (as mentioned in the previous post in this series), Sterile Processing professionals have a uniquely important contribution to driving down the rates of HAIs in general and SSIs (surgical site infections) in particular. That contribution is our ability to catch bioburden or residual debris on surgical instruments before they make their way into sterile packaging systems and finally to the OR suite. The primary means of reducing bioburden in SPD happens through the decontamination process of pre-cleaning, manual cleaning, and automated cleaning. However, the last line of defense against bioburden making its way back up to the Operating Room happens at the inspection & assembly stage during preparation & packaging.

With all of the work that goes into creating and maintaining a sterile field in the surgical setting, it is all for naught if our SPD teams miss residual bone in a rongeur, bioburden inside a Frazier suction, or tissue remaining on Adson Forceps during the instrument assembly phase of reprocessing. There are few more important steps in the process than before you seal up the container for the last time until it is opened in the OR. Make it count.

9. Reduce the Risk of Fires

AORN estimates that there are 200-240 fires in the OR per year in the US.  For a fire to occur, three things must be present: a fuel, and ignition source, and an oxidizer. Fuel is prevalent in the Operative setting, including alcohol-based skin preps, drapes, sponges, and other items.  Oxidizers could include anything from room air to an oxygen-enriched environment by using oxygen in the procedure.  The ignition source can be anything that provides enough to start a fire.  An example that can be influenced by Sterile Processing is light cords.  Fiberoptic light cords carry light from an OR light source through fiberoptic glass fibers to a scope.  If the light cord is damaged, the cord may produce high temperatures at the break, and not at the end of the cord as expected.  These high temperatures at the break of the light cord or at the connection to the scope could result in a fire.  Sterile Processing Technicians should carefully inspect light cords for damaged fibers during reprocessing and should confirm that the light cord is appropriately sized for the scope it is to be used with.  Insulated laparoscopic instruments should be tested for insulation integrity, as unexpected arcing of electricity could cause harm to the patient or be an ignition source of an OR fire.

10. Map Out Your Fire & Employee Safety Plan for Sterile Processing

One aspect of every Sterile Processing technician’s competencies is knowledge of the locations of various safety-oriented equipment within the department, such as fire extinguishers, fire alarm pull stations, eye wash stations, and safety showers. Even though many team members may have been working in the department for years, it is easy to succumb to “surroundings fatigue,” where being in the same place around the same things day after day actually causes you to forget they are there. A common result of this fatigue is forgetting the exact locations of important safety tools such as fire extinguishers.  Since there is rarely a need to use such equipment, many staff members are tempted to forget they even exist, causing consternation when they are quizzed on the locations of the department’s fire extinguishers during their annual competencies review.

Unfortunately, other safety equipment like emergency eye wash stations also become “invisible” in the minds of techs who are not consistently reminded of their location. There are creative ways to remedy this problem. It can be as simple as posting visual aids outside the employee break room to help cure the surroundings fatigue with blueprint-like maps that utilize widely understood safety symbols to highlight where this equipment is located within the department. In order to make these maps as easy as possible to reference, you can also create pocket-sized versions for technicians to carry or affix to their name badges.

11. What Do You Need to Know about Adverse Events?

Adverse events are defined by the Institute for Healthcare Improvement as “unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment, or hospitalization, or that results in death.” What constitutes an adverse event will vary between institutions, but the institution’s definition must include state and/or federal reporting requirements.  Adverse Events are managed at an organization by investigating the cause of the event, documenting what occurred and what actions were taken, resolving the issue, and communicating the event and resolution. Adverse Events are documented, usually in an electronic reporting system.  Adverse Event reports are reported voluntarily by team members and are site-specific to which area or unit the event occurred.  Unfortunately because the reports are voluntary, adverse event reports do not always accurately represent true safety trends in the organization, since not all events get reported. Statisticians call this effect “selection bias”, and it misrepresents the true nature of safety issues within the organization.

12. Why Do Staff Avoid Reporting Adverse Events

One of the main reasons healthcare professionals fail to report adverse events is the fear of getting in trouble.  They fear that the report (which will be reviewed by senior level leaders in the organization) will reflect badly on themselves or their peers, and they choose not to report it.  Similarly, they might choose not to report an adverse event because they don’t want to get another unit in trouble who was involved in the event.  They reason that reporting the event will erode trust between the departments and could cause the other department to retaliate in some fashion.  Both of these fears (retribution and retaliation) must be actively combatted by the organization’s leadership, since adverse-event reporting is one of the primary ways an organization will know the true picture of the quality of care they provide.  For event reporting to succeed, the organization needs to develop a strong patient safety culture.  Without such a culture in the organization, most patient safety initiatives will fail.

13. Creating a Patient Safety Culture: Communication is Open & Honest

The first step in creating a patient safety culture in an organization is to foster communication that is both open and honest.  This commitment involves every team member in the organization, and it starts with the leadership of administration encouraging an environment where people will be heard.  Every team member must be committed to reporting adverse events so that the root issues can be resolved.  The start of any journey of improvement must start with an accurate picture of what the problems are.  In Sterile Processing, this means that the department, at every level, should embrace reporting on the quality of their surgical sets, number of events related to improper processing, and percentage of times instruments must be “turned-over” from one case to another, etc.  When SPD is experiencing safety issues related to the OR (such as improper point-of-use cleaning), that feedback should be given specifically, honestly, and consistently to help that OR team make the appropriate adjustments.

14. Creating a Patient Safety Culture: Emphasis on Team Rather than Individual

Teamwork is globally recognized as an effective tool in delivering safe patient care (See World Health Organization’s “Being an Effective Team Player”, https://www.who.int/patientsafety/education/curriculum/who_mc_topic-4.pdf) Teamwork is more than a group of skilled employees working together on the same project or toward the same goal.  Teamwork is a strategic process where employees fulfill their specific roles and build collaborative relationships.  In a team environment, the task at hand (and the final outcome for the patient) takes precedence over personal interests or conflicts of personality.  Team members stay committed to following the policies and processes of the department to ensure the goal is attained.  For instance, team members with a goal of 100% clean instruments in the assembly area must be committed to following the appropriate steps in decontamination without shortcut, regardless of pressures from the OR or fatigue from working a long shift.  Department cultures that lack teamwork have employees that are focused on self-preservation, self-promotion, or self-ease as a higher priority than the department goal of safe patient care.

15. Creating a Patient Safety Culture: Standards & Practices Developed in a Multidisciplinary Framework

One of the challenges in the healthcare setting that makes designing safe processes difficult is that separate units and departments have very little collaboration and sharing of resources.  Each department is motivated to protect their own team, improve their own budget and productivity, and those desires can conflict with the best interest of the patient at times.  With this kind of “silo” mentality, employees are encouraged to do their job with a kind of self-preservation in mind.  This can result in more handoffs of the patient, more caregivers involved in completing tasks, delays in giving care, and miscommunication. This is why it is best to develop standards and practices in the context of a multidisciplinary team that represent various units and skills.  Sterile Processing can encourage a team environment with the OR by collaborating with them on issues like point-of-use cleaning and logistics of sterile instrument case cart deliveries. Involving Infection Control can help ensure the agreed upon processes comply with best Infection Prevention practice.

16. Creating a Patient Safety Culture: Staff Are Helpful & Supportive of One Another

One of the primary reasons healthcare workers fail to prevent harm to patients is that they do not feel at liberty to ask questions of one another or to express concerns to one another.  If the environment is cold and hostile between team members, newer staff members in particular will choose to live with a mistake before taking the vulnerable step of asking for help. In Sterile Processing, when we go out of our way to welcome and support new employees, it encourages open communication and invites questions.  The team needs to feel comfortable speaking to each other about safe practices as well.  If a technician sees their peer starting their shift without performing hand hygiene, they should feel safe and at liberty to gently remind their co-worker to wash their hands.  To promote this kind of safety culture, every team member needs to be frequently reminded of the urgency and the patient-impact of being helpful, approachable, and supportive.

17. Creating a Patient Safety Culture: Staff Trust One Another

Building a culture of Patient Safety involves building a culture of trust.  So much of patient care depends on handing off responsibilities to the next caregiver, team members need to feel confident that they can trust that the process in place will get the job done.  Staff members that don’t trust one another sidestep the process, finding workarounds to try to take care of things themselves.  Sterile Processing Technicians that are hesitant to hand off the priority turnover instrument set to the underperforming technician in Decontamination for cleaning are likely to cause delays as they take on their peers’ responsibilities.  While they are busy taking care of their peers’ responsibilities, they are more likely to forget important steps in the process (like internal indicators) or forget an important OR request (like a needed instrument set).  So how does your SPD go about building a culture of trust?  It isn’t by practicing high school camp-style trust falls; it starts with holding team members accountable to the same standard of competency.  When team members act in a trustworthy way, their peers will be able to trust them.

18. Creating a Patient Safety Culture: Team Members Emphasize Credibility & Attentiveness

Why do the SPD techs in your department come to work every day?  Is their top priority getting the easiest assignment, getting to pick the music in the department, topping the department’s productivity leaderboard?  In a culture that is safety oriented, team members prioritize protecting patients from harm. They will not allow music, assignment rotations, the overwhelming workload, or the drama at work distract them from carefully cleaning and inspecting surgical instruments.  Technicians should regularly be reminded that the work of Sterile Processing is a matter of life and death, and that we are in the business of saving lives.  Cliché as it may be, technicians ought to process every instrument as if it would be used on a loved one.  As such, department training and competencies should set an expectation for the quality of work performed.  Technicians should be coached and motivated to emphasize attention to detail in their work and to conduct themselves with integrity and credibility.

19. Creating a Patient Safety Culture: Environment Encourages Creativity & is Patient Outcome-Driven

Even the most capable and imaginative leader cannot put together a perfect process for safety and efficiency.  They don’t have the day-to-day work experience with the project, and they lack the diversity of backgrounds, ideas, and perspectives that the remainder of the team brings.  Often the best solutions for simple, efficient, safety-oriented process improvements come from the team members who work with that process on a daily basis.  One effective way of building a patient-safety culture is to have systems in place that encourage employee creativity.  Leaders should have formal pipelines set up for their employees to suggest process improvements, and employees should be awarded for ideas that improve department results.  When everyone on the team has their senses tuned in to looking for process improvements while they work, they will begin to uncover unneeded steps, high-risk processes, and inefficient workflows.  Don’t be afraid to try small adjustments to the process (on a small scale) to see how it affects department performance.  Small wins in these trials get people’s minds turning!

20. Creating a Patient Safety Culture: Focus on Workflow & Process

When thinking about how to make our work safer for patients, we quickly discover that the lowest form of error prevention is reminders: “Be more careful.” People don’t come to work to make mistakes or cause harm, and reminding them to “Be more careful” is likely not going to prevent them from making another mistake in the future.  But this is the solution we implement for errors many times: “Employee Coached.” In addition to coaching we also need to be looking at the process and workflow that led to the mistake.  Was this employee working with a process that was error-prone or unsafe?  Would another employee of the same skill level have made the same mistake in that circumstance?  While reactively educating employees after an event has happened is an important step, the resolution to the problem needs to be focused on what changes can be made to the process to prevent the error from occurring in the future.  One example of mistake-proofing in Sterile Processing might be building sterilization parameters into the tracking system to prevent a technician from accidentally steam sterilizing a flexible scope.

21. Creating a Patient Safety Culture: Learn from Events & Near Misses

Part of developing a patient safety culture is to learn from adverse events and near misses.  An organization should see a safety event as an opportunity to improve, not a marring statistic to record.  Whenever an error of any kind occurs, the gut reaction of the team should be to investigate the root cause of the problem and resolve it.  Here’s an illustration: if you heard that a friend had fallen down the stairs in their home, and you discovered they had tripped on one of the many children’s toys scattered on the stairs, your first thought wouldn’t be “you should be more careful next time.” I’m sure your advice would instead be, “you should get the toys off the stairs.”  If healthcare organizations only operate at the level of “be more careful next time,” they will not be one that learns from their mistakes.  Instead, if they work diligently to discover the root of the problem and seek to address that process problem across the organization, they will be one that learns from events and sees a gradual decrease in harm across the organization.

22. Safety Starts Here

This wraps up our 23-part educational series on connecting patient safety to the critical contributions made by Sterile Processing professionals across the country. As you learned in this program, national patient safety goals are more than just a list of good ideas. They really are a great launching point to spark conversations among your entire surgical service team about how you can work together to overcome risk, build in safe practices, and ensure better outcomes for your patients. We hope this content serves is the beginning of something of long term value and growth for your Sterile Processing team.

Our team at ONE TRAY® is honored to have you join us for this series.  Now that you have completed the program, make sure to complete your Safety Starts Here CE quiz.