The organization’s Office of Quality Monitoring finds the following 12 things are the most common reasons organizations are non-compliant with IC.02.02.01:
1. Staff belief that risk of transmitting bloodborne pathogens or bacterial agents to patients is low
2. Lack of staff knowledge or training on proper equipment sterilization or high-level disinfection
3. Lack of staff access to or knowledge of evidence-based guidelines
4. Lack of leadership support
5. High leadership and/or staff turnover puts equipment sterilization or high-level disinfection lower on the organization’s priority list.
6. Lack of safety culture surrounding safety risk reporting
7. Staff do not follow sterilization procedures properly
8. Staff do not take the necessary amount of time required to sterilize or high-level disinfect
9. There is no dedicated staff person to oversee the proper sterilization or high-level disinfection of equipment
10. Space issues or facility design prevent proper sterilization protocol or instrument storage
11. Lack of monitoring or documentation of sterilization or high-level disinfection of equipment, which makes it difficult to track the use of equipment on a specific patient, complicating the patient notification process when an outbreak occurs
12. Equipment is spread throughout the facility and may be processed or stored in numerous locations, making it difficult to track the equipment for documentation purposes
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