BC Children’s Hospital Mistake-Proofing

Equipment Reprocessing

Laurence Bayzand

Janice Penner Sue Fuller Blamey

Case for Collaboration

•Patient Safety Learning System (PSLS) trending identified an increased number of safety events related to reprocessing

•Despite the best efforts of front-line staff, the problems persisted

•A Task Force was struck to investigate and provide recommendations

Task Force Objectives

•To address failure modes, contributing factors, and mitigation strategies for reprocessing of surgical equipment, and missing and broken equipment •To identify how to work together to increase communication and draw on the wisdom of staff across the affected departments

Collaboration between teams

•Assembled a team of physicians, nurses, leaders, reprocessing staff, aides and quality leads

•Conducted a Failure Modes Effects Analysis

•Concurrently, conducted an external review using a Reprocessing expert to specifically review CSA

reprocessing standards

Types of events

•The Task Force began to track safety events

•There was a range of events identified:

–Packaging integrity issues

–Improper assembly

–Missing equipment

Type of OR Patient Safety Events Involving Sterile

Instruments

0

2

4

6

8

10

12

14

16

18

20

1

Type of OR Patient Safety Event

# of

Eve

nts

Improper or

incomplete assembly

of equipment

Package integrity

compromised

Suture tails in trays

Tissue or Blood on

sterile instruments

Missing chemical

indicators

Instruments not

ready

Paper on tray

Missing equipment

but not noted on

package

Reprocessing

equipment not

operated correctly

Containers missing

locks or filters

Dead ant on tray

Scopes not washed

Failure Modes Effect Analysis

Reprocessing of OR Equipment FMEA –

November 30, 2011

1. Scrub Nurse

rinses and wipes

tissue debris from

instruments in OR

2. Lumens are

rinsed and flushed

with sterile water

by OR nurse.

3. At the end of the

case, OR nurse

separates heavy and

delicate/sharp

instruments and places

them in water in bins in

OR room

4. Move

instruments to

decontaminated

area (hallway)

5. Tray

identification: If

instruments sets

take more than

one bin, bins need

to be labelled

together

6. Bins are placed

in the transport

cart by OR core

aide

7. Q2hours,

transport porters

arrive and

transport cart to

SPD

decontamination

area

8. SPD technician

rinses instruments

in the sink in

decontamination

area – lumen and

suction cannulas

are flushed before

ultrasonic cleaning

9. SPD technician

puts instruments

in ultrasonic

machine cleaning

10. SPD

technician

disassembles any

removable parts

11. Equipment is

placed in

instrument cradle

prior to going into

washer

12. SPD

technician sorts

instruments

belonging to the

same set together

in the automated

washer

13. Weekly

Sonocheck, TOSI,

test, lumen check

to evaluate

washer

effectiveness –

ensure that

equipment works

properly

14. Once cleaning

steps completed,

instruments are

placed on trays for

assembling sets –

2 technicians – 3-

4 others help

15. Visual

inspection of

instruments – look

for tissue – 5 min

– 1 hour – Return

instruments to

decontam area if

soiled.

16. Daily hemo

checks – test for

leftover blood on

instruments.

17. Trays re-

assembled.

Presently, if there

is missing

equipment, there

is a tape that is

placed on the top

of the tray after

rapping that lists

that equipment is

missing.

18. Double check

after equipment is

assembled of

small parts or

numerous

instruments in CT

scan sets and

implants only.

19. Improved seal

on pan – easier to

determine

tampering or

inadvertent

breakage

20. Tray wrapped

or placed in rigid

container

21. Tray is

labelled on top

and side

22. Tray is placed

in autoclave

23. Inspection of

wrapped

equipment

24. Daily

equipment checks,

biological indicator

for implants or

machine

25. Cool tray for

60 min before

dispatch

26. Place tray on

transport cart

27. OR core aide

places equipment

on OR carts

OR

SPD

New

a) Use instruments are not separated and put in the

same bins

b) Instruments are left in tray without soaking

c) Not enough water in the bins

d) Sharps are mixed in the bins

e) Priority or ASAP items don’t get placed in correct

bin.

f) Unused equipment does not get cleaned

g) Tissue/sutures do not become loosened from

instruments

a) Sets get separated , lost or

orphaned

b) Increases the chance that

instruments get mixed up

a) Porters are late so

dirty equipment waits

longer with increased

chance of sticky tissue

to equipment

a) Instrument sets

get separated

b) Instruments get

broken or

damaged

a) Equipment is

contaminated or broken

b) Second check is when

equipment is assembled so

it is difficult to see all

instruments.

a) Wrong instruments

assembled in sets

b) Broken or missing

instruments in sets

c) Dirty instruments

a) Wrapper has a

tear

b) Wrapper comes

undone

Analysis Worksheet per Failure Mode

HFMEA Sub process Step Title and Number

STEP: 3. OR nurse separates heavy/delicate/sharp instruments and places them in water in bins in OR room.

HFMEA Step 4 – Hazard Analysis HFMEA Step 5 – Identify Actions and Outcomes

Scoring Decision Tree Analysis

Failure Mode(s): Potential Causes

Seve

rity

Prob

abili

ty

Haz

Sco

re

Sing

le P

oint

W

eakn

ess?

Exis

ting

Cont

rol

Mea

sure

?

Det

ecta

bilit

y

Proc

eed?

Action Type (Control, Accept,

Eliminate)

Actions or Rationale for Stopping

Outcome Measure

1. Failure to recognize bins. Minor

Frequent 4 N N N Y

2. Human error. Minor

Frequent 4 N N N Y

3. Nurse overwhelmed with OR activities.

Minor

Frequent 4 N N N Y

4. Inexperience/lack of training.

Minor

Frequent 4 N N N Y

a) Used instruments are not separated and put in the same bins. b) Instruments are left in tray without soaking. c) Not enough water to soak. Instruments not immersed.

5. Standard work not completely rolled out.

Minor

Frequent 4 N N N Y

C 1. Education of OR nurses. 2. Labelling the bins prior to inserting instruments, if you require more than one. (Barb McKnight, Lorna) 3. Determination of a color/number scheme to label bin. (HOLD until determination of ways to clean equipment. i.e.: water in bins vs enzyme. 4. Investigate alternate ways of cleaning instrument other than soaking. Viola Tang to identify the choices of enzymes, gels, sprays, foams that are available in Supply Chain and check with other Health Authorities to see what they use. Susan H. to check with Risk Leads in other HAs to obtain their April Re-processing review report. 5. Determine if it is the Core Aide or Nurse filling up the bins with water (Janice/Barb)

Dec 9 2011-12-01 # of PSLS events Observation audits

Recommendations

•Implementation of enzymatic gel prior to sending to SPD

•Installation of upgraded automatic endoscope reprocessor machine

•Purchase of additional surgical instruments

•Upgraded SPD workstations

Recommendations

•Created process for unused equipment

•Reinforced process for ASAP items

•Revised equipment assembly process in SPD including structural changes to room

•Increased frequency of transport of items to/from SPD

Recommendations

•Improved storage for sterile trays in the OR

•Structural changes to soiled area in OR and decontamination area in SPD

•Eliminated redundant decontamination processes

Lessons Learned

•Collaboration is an effective way to create improvements in practice across departments

•It is important to identify and mistake-proof all root causes

•Communication is critical in creating trust amongst team members and maintaining gains

•Questions?