TJC Survey Findings Seen in 2017

by dawnconrey

TJC Survey Findings Seen in 2017

by dawnconrey

by dawnconrey

More Sophistication Mandated in High-level Disinfection & Sterilization

Last year one of the most frequently scored standards was IC.02.02.01, EP 2 dealing with defects in the high-level disinfection or sterilization processes. That is continuing this year, but the sophistication and array of different issues scored against this EP is much more diverse.

No longer is it just a simple Cidex test strip issue. More often today we see noncompliance with:

  • manufacturer’s instructions for use (IFU) to pre-clean or sterilize
  • failure to pre-clean per evidence-based guideline (e.g., AAMI ST79)
  • failure to transport in a covered, rigid container
  • failure to label that rigid container with a biohazard label
  • arm hair exposed in the sterile prep and pack area of central sterile supply
  • failure to maintain sterilizers and washers per IFU
  • failure to perform and document biological indicator testing properly (e.g., having the control and load BI lot numbers not match)

Probably the two greatest risks we are seeing right now is a failure to use a covered, rigid container or include a biohazard label on that rigid container when transporting contaminated instruments or probes. This does not just apply to the OR area, but every clinic (e.g., wound care) or department (e.g., bedside procedures) using non-disposable surgical instruments that are slated to arrive in Central Sterile for reprocessing. You want to know that you have given staff in these locations the tools they need to achieve compliance. You can’t carry a sharp from the bedside to the dirty utility room in your hand or in a towel. Per section 6.4 of AAMI ST79, depending on the item being transported, a suitable container (e.g., with a sharp instrument, a rigid, covered container is needed) marked with a biohazard label should be used to move the item from point A to point B. Once you have moved the item from its point of use to the dirty pick up point you also need to ensure that pre-cleaning takes place that is appropriate for that instrument (e.g., follow the instructions for use, or IFU) and that the pre-cleaning “wetting” agent is approved by the IFU to keep the instrument “moist” for the duration that the item will sit in the dirty utility room until picked up for processing.

Subsequent blog postings this month will report on additional findings seen thus far in 2017.  Please stay tuned!

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