By Tony Thurmond, CRCST, CIS, CHL, FCS
When errors in sterile processing (SP) occur, the department’s leader and team members must fully explore the reasons behind those incidents and promptly seek effective solutions – and they shouldn’t wait, either. The sooner errors are addressed and mitigated, the better the outcomes for health care customers and patients.
It’s important for SP professionals to recognize that all errors present opportunities for positive change; however, in order for that to happen, facilities must adopt a proactive rather than reactive approach. Reactive strategies can often be “Band-Aid fixes” that typically fail to allow positive opportunities for change. A proactive approach, on the other hand, allows better foresight into the error, with anticipation of removing future barriers.
In the SP environment (and virtually all other health care departments), errors do occur, and it is never fun when they do. Changing how errors are approached and exploring opportunities to understand their full impact and reduce future errors is essential. Put simply, we must look at the attitude toward mistakes, the barriers that allow for errors to occur, the reaction to our errors, and the best solutions for eliminating and preventing them in the future. What follows are four key factors that SP leaders and technicians must consider:
ATTITUDE: If individuals do not grasp an error’s impact, they will never have the insight to make corrections. As a manager, it is challenging for me when an employee has the wrong attitude or approach to an error. I once had an employee tell me, “We should be able to make three or four mistakes a month” (obviously unacceptable). That same employee also tried to convince me that a mistake should only count when it is found in the operating room (OR) or other patient care area. Certainly, this sort of reasoning failed to keep the patient and our quest for quality at the forefront.
Conversely, I have had employees who wanted to dig deeper to understand how an error occurred and how they could prevent future incidents. As a manager, I have taken a technician to the OR to discuss an error with the surgical team. We have all gotten those calls from surgeons who want us in the room immediately because they want to vent their frustrations about the error and hear how we plan on preventing another error from happening in the future. Seeing our sincerity in handling the issues goes a long way. Taking a technician into the room to observe that interaction is beneficial, so the technician sees the error’s full impact. They can then share with their co-workers what they learned and explain how they saw the patient who was (or might have been) impacted by the error. Visualization is an especially effective training tool.
BARRIERS: SP professionals must demand that they have what is needed to make them (and their teammates) successful in their given tasks (across all areas of the department). Barriers such as improper or inadequate cleaning equipment or tools in the decontamination create opportunities for shortcuts and oversights. Other barriers might include inadequate training or a lack of training materials for each technician. Each department should have a copy on file of the most current standards and guidelines, as well as all current manufacturers’ instructions for use for the items being handled/managed by the department (this also includes operating manuals for the equipment in use in the department). Education must be provided to each technician within the department, and it should be developed for department-specific work. Ongoing reviews of the processes in place (and new processes as added) should be performed, along with a return demonstration to ensure each technician understands the task and how it should be performed. Daily huddles are also effective for communicating the day’s events and expectations for the next day, and for discussing any error that may have occurred (and any customer concerns or complaints).
REACTIONS: Taking ownership of an error when it occurs isn’t always easy, but it is critical to success. The key to admitting mistakes is to learn from them, correct them and move on. Sincere apologies and the effort to admit the error and make necessary improvements are the best approaches for all involved.
SOLUTIONS: Being proactive is the best measure for reducing errors. Solutioning a problem involves the following critical steps:
- Continuous review of the needs of the department. Seek opportunities to improve the safety for each worker. Proper personal protective equipment, tools, cleaning agents, equipment, training, etc., all will create a better working environment for staff.
- Continuous review of the policies and procedures of the department to give staff the best processes and direction for handling issues.
- Continuous monitoring of your instrument tracking system for recipe improvements, as well as reviews with the staff on sterilization monitoring and documentation.
Last but certainly not least, human factors, which are ever-present, should be strongly considered whenever errors occur. Many managers struggle to determine the appropriate actions when a technician makes an error. I personally strive to look at each situation and then look for the barrier that may have contributed to the error. I try to let each technician know about the error made and then determine whether they are experiencing any challenges. During these conversations, managers will hope for technicians who are responsive to the discussion or situation and then be willing to find solutions to reduce risks for a recurrence. During these discussions, I’ve found it helpful to educate and show empathy while pushing the ever-important message that the patient could have been impacted by the error.
– Tony Thurmond, CRCST, CIS, CHL, FCS, serves as central service manager for Dayton Children’s Hospital. He is also a past-president, fellow and columnist for the Healthcare Sterile Processing Association (formerly the International Association of Healthcare Central Service Material Management).
