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"Extremely Dangerous, and Potentially Fatal Outcome for Patients": Another Anonymous Letter from SPD

Updated: Oct 22, 2023

(We recently received another anonymous letter from one of our listeners. It is another poignant reminder of the reality of far too many Sterile Processing departments and earnest professionals in our industry. These are the real challenges facing our teams today. We can't afford to ignore it.)


"In reading the anonymous letter to the Sterile Processing Industry I was stunned to find out that my hospital was not the only hospital that has a "dirty" secret! I felt compelled to respond as I have been living in silence far too long. I ask that you keep my response anonymous as well.

 I have been doing Sterile Processing for four years now. I am merely a toddler in a trade full of lifers who have been doing this for twenty plus years. In my time of training and learning, I have been shaken to the point of taking a step back and only working on the weekends. The things that I have witnessed have made me terrified to ever have surgery. 

Dirty floors, contaminated clean areas, and mishandling of instruments is just the tip of the iceberg. I have witnessed people cutting corners and literally jeopardizing the life of the patient. Countless times there has been bio-burden found by the OR on instruments that were supposed to be clean and sterile. I have seen techs take trays out of the case cart in decontamination and shove them in the washer without inspecting them and hand washing them. I have witnessed robotic arms going straight into the washer, skipping the twenty min pre-soak and ultrasonic all together. 

I personally have been ordered by my supervisor to hand wash ortho instruments that were knowingly contaminated with Hepatitis C, and put them through the window so they could be flashed, or IUSSed, for the next case. 

No one ever conducts the proper test on the lap grasper tubes to ensure there are no knicks or holes in the tube. In fact I am not certain what the test is called, because we never do it. The only reason I know we are supposed to is because of the inservice. Our machine does not work to test them. I am told that if there is a hole in the tube the patients intestines could be burned and the doctor wouldn't know it was happening until it was too late. 

Countless times we have been ordered to disregard IFUs for the sake of a speedy turnover. Too many surgeries, not enough sets or staff, and bad management contribute to this problem. Every person feels as if they are under paid, overworked, and unappreciated. People get burnt out. I believe this problem will continue until the staffing crisis ends, management issues are addressed, management is held accountable, and pay rates go up. Most importantly it will continue until the techs feel safe enough to speak out without fear of losing their jobs

I work for the largest healthcare network in my area. I have worked in five different facilities within this system. They all are the same. Almost everybody turns their head and looks the other way. Seniority rules and management takes a passive role. The departments are being run by the techs who have been employed the longest, not management. All of this adds up to an extremely dangerous, and potentially fatal outcome for patients. "

Anonymous Email Submission, July 2019

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