6 Common Errors in Surgical Instrument Processing

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Proper management of resources as well efficient and effective cleaning, assembling and sterilizing of surgical instruments are imperative to a well functioning perioperative service line.

Alpha Consulting Group is a national consulting firm specializing in providing advisory services to hospitals and facilities facing challenges in the OR. The firm often ensures that AAMI guidelines and AORN Recommended Practices are followed.  Frequently, they identify variations in practice that do not meet these guidelines.


1. Productivity measurement. The productivity standard for labor in a sterile processing department is not consistent from hospital to hospital. We've observed many different standards, including average daily census, adjusted patient days and surgery cases. Of the three that are listed, the surgery case volume is probably a closer indicator of the workload within SPD, but it does not factor in the acuity level of the cases.  For example, a facility could have 10 cases on one day that include three hernias, a couple of D&Cs and a few hand cases.  The workload on a day like this would be very different from a day that included four total joints, two spine cases, an open heart, and a few other procedures.  

To get a true picture of the workload, the best statistic for sterile processing productivity is the number of trays sterilized per day. Tray volume is easy enough to track. It can be done manually by counting up the number of trays on each load card, which is necessary documentation for tracking sterilized trays, or hospitals that have an automated instrument tracking system could run a daily report.  A system like this ensures that you have the appropriate amount of resources available to meet the work requirements of the area and prevent delays in other high cost departments like surgery.

2. Consolidating sterilization responsibility. Hospitals may perform sterilization and high-level disinfection in multiple locations. Examples of departments that may have separate equipment include the ambulatory surgery center, an endoscopy lab, labor and delivery, inpatient operating room and the sterile processing department itself. When performing an operational assessment of all invasive procedure areas within a hospital, we frequently find that each department is individually responsible for the monitoring of their sterilization processes and equipment.

We have also observed documentation systems for ensuring sterility differ between those departments and the quality of the sterilization record keeping system are inconsistent through all areas. We recommend that all sterilization practices be monitored and managed by the sterile processing staff. This practice yields consistency in operational standards as well as documentation and record keeping.

3. Following manufacturers' processing recommendations. The complexity and sophistication of instrumentation used in new techniques requires strict adherence to the manufacturers' recommendations for cleaning and sterilizing their products.  Whether it is high-speed power equipment, minimally invasive instrumentation or robotics instruments, there may be several steps in the cleaning process, and there may also be extended sterilization time requirements. Sterile processing departments must develop methods to identify items that require special treatment and have protocols in place to ensure that standards are met. There are a number of resources available to obtain the information and it needs to be readily available to your sterile processing staff so that they remain in compliance.

4. Effective resource management
. There are many products on the market today to help a sterile processing department manage their tray recipes/count sheets and to provide an inventory of available instrument sets and their location throughout the hospital. There are still many facilities that do not have the resources to obtain that level of sophistication, or do not have the personnel to manage such a system. It is very difficult to determine your resource needs when you do not have an inventory of what is currently available within the organization. 

This can be easily resolved by building an inventory list in an Excel spread sheet and it can be further "customized" by adding factors such as the specialty category and/or storage location. As trays and instruments are purchased, only one file needs to be accessed to update the information.

5. Pre-treatment
. During a surgical procedure it is the responsibility of the surgical technician to keep the instruments relatively clean and free of bioburden. Wiping down soiled instruments with sterile water through the case usually does this. At the end of the case, contaminated instruments should be placed back in their tray and at a minimum, covered by a towel moistened with water, or better yet, covered with enzymatic foam that can start to break down the bioburden remaining on the instruments.

Instruments should not be thrown into a basin with liquid for a number of reasons including the potential for splashing and spills, potential damage or dulling of more delicate instruments, and extended reassembly time due to mixed up or misplaced instruments.

6. Confinement and containment of dirty instruments.

While an enclosed case cart is the best way to transport dirty instruments outside of the operating room, we realize that this is a large capital investment for some hospitals to make. There are still effective ways to transport dirty instruments, even if an open cart is used. A short cut that has been observed and is not appropriate is to keep the instruments on the surgical back table and to fold the back table cover back over the instruments to transport them to SPD. 

This process does not contain the instruments properly and the back table cover is potentially contaminated with blood and body fluid. An acceptable approach is to treat the instruments as suggested in #5 and place them on an open cart. Utilize a disposable plastic cart cover that is labeled for bio hazardous waste to cover the cart for transport to the sterile processing department.

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By avoiding these common errors, a hospital can ensure that they are providing well-maintained, sterile instruments to their patients in the most efficient manner possible.

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