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Health officials determined that the infection control breach was due to human error that occurred during “a gap” in the manual pre-cleaning phase — before the instruments underwent heat sterilization. The instruments likely still contained bioburden when they were sent along for automated cleaning and heat sterilization.3
Improper or inadequate decontamination, cleaning and sterilization of surgical instruments continues to be a major source of patient harm that is preventable through proper practice and adherence to manufacturers’ instructions for use (IFUs). by placing the contaminated instruments into sterile water or an approved enzymatic detergent.
Over the past year there has been a lot of increased emphasis and attention placed on pre-cleaning surgical instruments at the point of use prior to transport to sterile reprocessing. Joint Commission then conducts their surveys/audits based on the standards that have been set for sterile processing activities. Section 7.3 Section 6.3.1
While this happened a few years ago, it is a great example of the incredible importance of pre-cleaning at point of use, proper decontamination and thorough cleaning of surgical instruments during reprocessing and prior to sterilization. The hospital said it identified a gap in the pre-cleaning process , prior to sterilization.
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