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Archive Infection Control 2019

Surgery's Dirty Little Secret

A closer look at why contaminated instruments continue to turn up in too many ORs.

Joe Paone

Joe Paone


Pamela Bevelhymer, RN, BSN, CNOR
TOUGH JOB Sterile processing departments are handling increasing numbers of complex instruments that are more difficult to clean and sterilize.

A Google news search of "dirty surgical instruments" will turn up several examples of surgeons allegedly operating on patients with soiled tools, including the highly publicized sterility issues that plagued Detroit (Mich.) Medical Center. How could that possibly happen? Gail Horvath, MSN, RN, CNOR, CRCST, senior patient safety analyst and consultant at ECRI Institute in Plymouth Meeting Pa., offers some insights. Her recent analysis of contaminated surgical instrument reports submitted to ECRI Institute by 123 hospitals identified several factors that can lead to reprocessing errors. How many need to be addressed in your facility?

1. Instrument complexity

Surgical instruments are becoming more functional and complex and, not surprisingly, more difficult to clean. The data bears this out. Ms. Horvath's research found that complex and cannulated or lumened instruments were identified in 75% of the reported dirty instrument events. She views this problem as the top contributing factor, especially in outpatient settings where orthopedic surgeries have significantly increased in volume and instruments get soiled by difficult-to-remove bone, debris and bioburden. Many newer surgical instruments have more parts, more pieces and more complex instructions for use (IFUs), points out Ms. Horvath. "When the instruments are under development by a device manufacturer, they're developed very well for their intended use and function," she says. "But often there's not significant recognition of how difficult they are to clean."

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