The Case For Quality

In an effort to improve quality, transparency and safety, the Health Authority Medical Quality Committee will begin sharing real stories about events that all medical staff can learn from. These anonymized stories summarize unique events that can jeopardize quality and highlight what medical staff can do to prevent them from recurring. Island Health is dedicated to providing care at the highest levels of quality and safety and every one has a role. Similar to the case examples in the Canadian Medical Protective Association’s magazine, these stories help remind all medical staff how we can provide better care.

How do you know the equipment is sterile?

Medical staff are the last line of defense is preventing sterilization failures. Although the Medical Device Reprocessing department cleans, disinfects and sterilizes medical equipment throughout the health authority, often the physician is the one wielding the equipment. Do you know how to identify if the equipment is sterile?

Earlier this year, medical equipment at an Island Health hospital was hand-washed and disinfected with an enzymatic cleaning cycle. Staff assembled, wrapped and placed the equipment in an autoclave for sterilizing but did not properly initiate the autoclave machine cycle - sterilization did not complete. The non-sterile instruments were delivered to surgical operating rooms, ambulatory care areas and inpatient units. This mistake was discovered during a routine surgical safety check. The equipment was recalled immediately but some of the disinfected, but unsterilized instruments had already been used for patient procedures by medical staff. Patients were informed and appropriate monitoring took place. Fortunately, no patient complications occurred.

Could this happen to you?

Any member of the team can identify sterilization failure in a number of ways. By ensuring all team members are familiar with the indicators of properly sterilized equipment, the risk of using inadequately sterilized equipment is reduced. Please take a minute to review this information sheet to identify sterilized equipment.