A3 Sue Fuller Blamey - BC Children's Hospital: Mistake-Proofing Equipment Processing
Transcript of A3 Sue Fuller Blamey - BC Children's Hospital: Mistake-Proofing Equipment Processing
BC Children’s Hospital Mistake-Proofing
Equipment Reprocessing
Laurence Bayzand
Janice Penner Sue Fuller Blamey
Case for Collaboration
•Patient Safety Learning System (PSLS) trending identified an increased number of safety events related to reprocessing
•Despite the best efforts of front-line staff, the problems persisted
•A Task Force was struck to investigate and provide recommendations
Task Force Objectives
•To address failure modes, contributing factors, and mitigation strategies for reprocessing of surgical equipment, and missing and broken equipment •To identify how to work together to increase communication and draw on the wisdom of staff across the affected departments
Collaboration between teams
•Assembled a team of physicians, nurses, leaders, reprocessing staff, aides and quality leads
•Conducted a Failure Modes Effects Analysis
•Concurrently, conducted an external review using a Reprocessing expert to specifically review CSA
reprocessing standards
Types of events
•The Task Force began to track safety events
•There was a range of events identified:
–Packaging integrity issues
–Improper assembly
–Missing equipment
Type of OR Patient Safety Events Involving Sterile
Instruments
0
2
4
6
8
10
12
14
16
18
20
1
Type of OR Patient Safety Event
# of
Eve
nts
Improper or
incomplete assembly
of equipment
Package integrity
compromised
Suture tails in trays
Tissue or Blood on
sterile instruments
Missing chemical
indicators
Instruments not
ready
Paper on tray
Missing equipment
but not noted on
package
Reprocessing
equipment not
operated correctly
Containers missing
locks or filters
Dead ant on tray
Scopes not washed
Failure Modes Effect Analysis
Reprocessing of OR Equipment FMEA –
November 30, 2011
1. Scrub Nurse
rinses and wipes
tissue debris from
instruments in OR
2. Lumens are
rinsed and flushed
with sterile water
by OR nurse.
3. At the end of the
case, OR nurse
separates heavy and
delicate/sharp
instruments and places
them in water in bins in
OR room
4. Move
instruments to
decontaminated
area (hallway)
5. Tray
identification: If
instruments sets
take more than
one bin, bins need
to be labelled
together
6. Bins are placed
in the transport
cart by OR core
aide
7. Q2hours,
transport porters
arrive and
transport cart to
SPD
decontamination
area
8. SPD technician
rinses instruments
in the sink in
decontamination
area – lumen and
suction cannulas
are flushed before
ultrasonic cleaning
9. SPD technician
puts instruments
in ultrasonic
machine cleaning
10. SPD
technician
disassembles any
removable parts
11. Equipment is
placed in
instrument cradle
prior to going into
washer
12. SPD
technician sorts
instruments
belonging to the
same set together
in the automated
washer
13. Weekly
Sonocheck, TOSI,
test, lumen check
to evaluate
washer
effectiveness –
ensure that
equipment works
properly
14. Once cleaning
steps completed,
instruments are
placed on trays for
assembling sets –
2 technicians – 3-
4 others help
15. Visual
inspection of
instruments – look
for tissue – 5 min
– 1 hour – Return
instruments to
decontam area if
soiled.
16. Daily hemo
checks – test for
leftover blood on
instruments.
17. Trays re-
assembled.
Presently, if there
is missing
equipment, there
is a tape that is
placed on the top
of the tray after
rapping that lists
that equipment is
missing.
18. Double check
after equipment is
assembled of
small parts or
numerous
instruments in CT
scan sets and
implants only.
19. Improved seal
on pan – easier to
determine
tampering or
inadvertent
breakage
20. Tray wrapped
or placed in rigid
container
21. Tray is
labelled on top
and side
22. Tray is placed
in autoclave
23. Inspection of
wrapped
equipment
24. Daily
equipment checks,
biological indicator
for implants or
machine
25. Cool tray for
60 min before
dispatch
26. Place tray on
transport cart
27. OR core aide
places equipment
on OR carts
OR
SPD
New
a) Use instruments are not separated and put in the
same bins
b) Instruments are left in tray without soaking
c) Not enough water in the bins
d) Sharps are mixed in the bins
e) Priority or ASAP items don’t get placed in correct
bin.
f) Unused equipment does not get cleaned
g) Tissue/sutures do not become loosened from
instruments
a) Sets get separated , lost or
orphaned
b) Increases the chance that
instruments get mixed up
a) Porters are late so
dirty equipment waits
longer with increased
chance of sticky tissue
to equipment
a) Instrument sets
get separated
b) Instruments get
broken or
damaged
a) Equipment is
contaminated or broken
b) Second check is when
equipment is assembled so
it is difficult to see all
instruments.
a) Wrong instruments
assembled in sets
b) Broken or missing
instruments in sets
c) Dirty instruments
a) Wrapper has a
tear
b) Wrapper comes
undone
Analysis Worksheet per Failure Mode
HFMEA Sub process Step Title and Number
STEP: 3. OR nurse separates heavy/delicate/sharp instruments and places them in water in bins in OR room.
HFMEA Step 4 – Hazard Analysis HFMEA Step 5 – Identify Actions and Outcomes
Scoring Decision Tree Analysis
Failure Mode(s): Potential Causes
Seve
rity
Prob
abili
ty
Haz
Sco
re
Sing
le P
oint
W
eakn
ess?
Exis
ting
Cont
rol
Mea
sure
?
Det
ecta
bilit
y
Proc
eed?
Action Type (Control, Accept,
Eliminate)
Actions or Rationale for Stopping
Outcome Measure
1. Failure to recognize bins. Minor
Frequent 4 N N N Y
2. Human error. Minor
Frequent 4 N N N Y
3. Nurse overwhelmed with OR activities.
Minor
Frequent 4 N N N Y
4. Inexperience/lack of training.
Minor
Frequent 4 N N N Y
a) Used instruments are not separated and put in the same bins. b) Instruments are left in tray without soaking. c) Not enough water to soak. Instruments not immersed.
5. Standard work not completely rolled out.
Minor
Frequent 4 N N N Y
C 1. Education of OR nurses. 2. Labelling the bins prior to inserting instruments, if you require more than one. (Barb McKnight, Lorna) 3. Determination of a color/number scheme to label bin. (HOLD until determination of ways to clean equipment. i.e.: water in bins vs enzyme. 4. Investigate alternate ways of cleaning instrument other than soaking. Viola Tang to identify the choices of enzymes, gels, sprays, foams that are available in Supply Chain and check with other Health Authorities to see what they use. Susan H. to check with Risk Leads in other HAs to obtain their April Re-processing review report. 5. Determine if it is the Core Aide or Nurse filling up the bins with water (Janice/Barb)
Dec 9 2011-12-01 # of PSLS events Observation audits
Recommendations
•Implementation of enzymatic gel prior to sending to SPD
•Installation of upgraded automatic endoscope reprocessor machine
•Purchase of additional surgical instruments
•Upgraded SPD workstations
Recommendations
•Created process for unused equipment
•Reinforced process for ASAP items
•Revised equipment assembly process in SPD including structural changes to room
•Increased frequency of transport of items to/from SPD
Recommendations
•Improved storage for sterile trays in the OR
•Structural changes to soiled area in OR and decontamination area in SPD
•Eliminated redundant decontamination processes
Lessons Learned
•Collaboration is an effective way to create improvements in practice across departments
•It is important to identify and mistake-proof all root causes
•Communication is critical in creating trust amongst team members and maintaining gains
•Questions?