By Tony Thurmond, CRCST, CIS, CHL, FCS
Sterile processing departments (SPDs) and operating rooms (ORs) are no strangers to the challenges of missing instruments. Such incidents can be attributed to numerous causes, both within the SPD and OR, and when the causes aren’t addressed promptly and effectively, procedures can be negatively impacted, along with interdepartmental relationships and satisfaction.
To manage the problem of missing instruments, it’s necessary to first attempt to uncover the cause – and understand how the facility responds when devices go missing. Do sterile processing (SP) technicians search for them or is a replacement device ordered promptly? Is the SPD tracking technicians to the specific trays they assemble? Is there confusion about a device’s proper name, which leads to the wrong device being placed in the set?
Instrument trays have a recipe or checklist of items needed for a complete set for a procedure. The recipe should include the catalog number of the instrument and the item description or name. Device nicknames used by OR staff can be included on the recipe in parenthesis, but it is essential to always include the manufacturer’s name of the device. Ideally, the SPD will have similar instruments that can be used in another’s place as needed. The quantity of suitable replacement instruments should be documented, along with pertinent instructions (e.g., the need for tip protectors).
Whenever a recipe change occurs, such as adding or removing a device or changing the manufacturer or quantity, those updates and the date they occurred must be documented and shared during team huddles and meetings. Poorly developed or insufficiently detailed recipes can contribute to tray errors and missing devices. Including instructions for disassembly and reassembly is also beneficial. Sometimes, technicians prepare trays so routinely that they may assemble trays without a thorough count or fail to follow the steps exactly as indicated on the recipe.
When trays arrive in the decontamination area, they are sorted and organized for proper visibility when going through the washers. It is not uncommon to find a missing instrument from one tray inside another tray used for the same procedure. Tracking tray usage is an effective way to locate missing instruments. Most technicians know when an instrument does not belong or when a cart arrives from the OR with mixed-up trays. Keeping devices together with a color-coded tab placed on each tray from the case cart is an effective approach. For example, if a cart enters the SPD with six trays, the same color tabs could be placed on each of the trays. When trays tagged with the same color go through the washer, and one has a missing DeBakey forceps, for example, the technician processing that color tab can check to see if it is in another tray. Effective resolution for missing or misplaced instruments take ongoing communication and education across all SP teammates as well as for interdisciplinary colleagues.
Tracking trays for accuracy
Facilities with a computer-based instrument tracking system can review multiple reports daily to examine tray availability and review missing devices and the technician who assembled the tray. When a missing item is noted and identified, the first step should be to search for it. If not readily located, technicians should check the repair bin. Trays with missing items can also be placed on a separate cart to prevent them from being mixed with complete trays. The trays should be tagged to indicate the missing devices.
If the missing instrument cannot be found, the tray can be opened to verify it is missing and not simply overlooked during the check. Of course, it is best to count correctly the first time to prevent having to open and reprocess the tray. SP technicians should stay focused and not allow time pressures to interrupt proper counts and documentation.
SP managers, supervisors and educators should ensure technicians understand what is required and whether they have the tools needed to manage their responsibilities effectively. This is essential to determine if additional training and resources are necessary. Sometimes, technicians may have the correct training and tools but express that tray recipes are too challenging to read or follow. In such cases, the manager should work to evaluate and improve the process. Auditing trays is also important for ensuring the correct instruments are present. It is better to audit trays before they are sterilized to ensure accuracy, as well as checking trays sent out for repair.
It is important to recognize that instruments are often lost during surgical procedures. In fact, instruments are often accidentally thrown out with surgical drapes or the back table cover. OR staff must be reminded to take caution when throwing away disposable items to ensure instruments and other reusable items are not tossed with them.
Conclusion
Missing or misplaced instruments are difficult to manage, but SPD and OR staff must work together to try and prevent its occurrence. Properly prepared tray recipes, effective communication, ongoing education and quality checks are the keys to ensure the correct devices are included in the correct tray.
– Tony Thurmond, CRCST, CIS, CHL, FCS, is an HSPA Past-President who serves as Sterile Processing Manager for Dayton Children’s Hospital.
