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What's Wrong with This Picture Wednesdays?

Pictures speak volumes and are often easier to remember than numbers; they create a visual imprint on our minds to correlate with data and take action. Throughout one's career, there are numerous examples of potential or actual healthcare-quality events. By sharing these stories, we can create provide meaningful insight into what went wrong, and what should have occurred to keep the next patient safe.

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This Wednesday's quality example is below:

S: Surgical Instrument tray returned to sterile processing for processing

B: Tray returned from C-section case

A: What is your analysis?

R: What is your recommendation?


The surgical tray was placed in an overflow surgical area near the processors. 1 cart had clean instruments ready to go into core, another cart contained completed sterilized instruments.

The tech grabbed a tray from the clean, not sterilized cart. Safety checks were missed upon retrieval, and prior to use.

The clean, non-sterile tray was utilized on a patient.

Sterilized trays contain multiple visual checkpoints to ensure sterilization. Visual tags are included on the handle of exterior tray, inside the tray and inside the lid of the tray. Once the tray is sterilized the visual indicators change color or markings.

Sterile cores serve the surgical team well when organized by service line, color coding, categorizing and function. Items stored in overflow (non-core) areas, are at risk for misuse, expiration. and cross contamination. Workarounds pose a risk to surgical safety. Lean methods utilizing carts that flow from clean (start) to finish (sterile) are beneficial and when combined with signage, color coding and geographic demarcations help to maintain safety.

Time outs in retrieving, inspecting and prior to utilization with checks and double checks retain surgical safety for the patient and team.

Lastly, the surgical tech in sterile processing found the unsterilized visual indicators and felt safe to speak up. Creating a culture of safety is the CORE of patient and team safety.

When was the last time, you as the healthcare executive checked in on your perioperative culture of safety?

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