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Thank You, Errors: Connecting the Dots on Surgical Instrument Reprocessing Challenges

Spend one day in a busy Sterile Processing department and you will be confronted with the critical impact errors can have on a surgical workflow. These surgical instrument reprocessing errors can lead to everything from minor inconveniences to life-threatening "never events." Forgotten indicators, incorrect light cord attachments, reversely assembled retractor handles, and bone-laden rongeurs -- the list of potential and actual errors can be incredibly long and understandably frustrating for surgeons, operating room personnel, and Sterile Processing team members.

As dangerous and disappointing as these errors can be, they can and should be teaching us something about our workflows, standard operating procedures, training, and tools. Errors are the check engine light on our department dashboard, signaling to us that something about the current process may not be all that it appears to be from the outside. Errors function much like the body's pain sensations when we get too close to fire, sending up a flare that says "Stop! What you are doing could end up badly for you!"

All this is straight-forward enough. Reprocessing errors, while dangerous, also give us invaluable feedback to the current state of our processes in SPD -- if we see them, document them, and respond to them. But wait, there's more...

What's the big idea? The Need for Networked Error Databases

Forgive me briefly if I use the tired and now nearly clichéd metaphor of the airline industry -- hopefully with a memorable twist. Imagine if each individual aircraft kept its flight error logs to itself. When a 737 had engine troubles, only that particular pilot and mechanic addressed it. When an Airbus A320 required an emergency landing in Nebraska, no one except the people on board ever knew anything about it. When jet liners across town crashed, no one ever connected the dots.

Let me just come out now and state the obvious -- THIS IS OUR REALITY in Sterile Processing. We keep our error data to ourselves. We track different metrics, we use different targets, and for the love of all that is professional -- we keep the quality challenges in-house.

What this means is that we have those damned silo walls so freaking high around our departments that only someone with a lot of nerve and a grappling hook could ever climb in and see what is actually going on in our facility. In the meantime, individual Sterile Processing departments across the country may be struggling with the exact same quality challenges (or completely different ones) and we would have no idea. There could be systemic "crashes" happening at 50 other facilities in the US due to insufficient inspection of aspirating needles, and our own department could be completely oblivious to it.

This is crazy. It's asking individual Sterile Processing directors, managers, and technicians to solve errors independent of any larger understanding of related industry challenges. It's seeing a pillar of fire and billows of smoke from a plane crash and knowing you'll never know why it happened or if it will happen to you next week.

If we do not share our errors with our larger network, neither can we share and create real solutions. I think a first step in this direction would be the creation of an Error Reporting Database for the Sterile Processing industry to begin putting data together that can be visualized and mined for critical insights to provide real process solutions to departments across the country. Without this, or something like it, we will be left to re-invent the wheel of processing improvement in 6,000+ hospitals around the US. That would never work for airlines and it hasn't worked for us either. It's time to talk to each other...

Hank Balch © 2020

Hank Balch is the Founder and President of Beyond Clean. You can follow him on Instagram @WeFightDirty, and find his Fighting Dirty video series on YouTube. He is an international thought leader and has written over 150 other Sterile Processing articles and commentary, along with published articles in Becker's Hospital Review, Infection Control Today, AAMI News, AAMI BI&T Journal, Outpatient Surgery Magazine, and contributions to Healthcare Purchasing News. Hank's CS/SPD team in Louisville, KY was named the "2016 CS/SPD Department of the Year" by HPN. He has also served as the founding President of the South Texas Association of Sterile Processing Services and President of the Kentuckiana IAHCSMM Chapter, in additional to being nominated for the 2017 President-Elect & 2018 President-Elect of the International Association of Healthcare Central Service Materiel Management.


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