TY - CHAP M1 - Book, Section TI - Standardization and Reliability A1 - Gitomer, Richard S. A2 - McKean, Sylvia C. A2 - Ross, John J. A2 - Dressler, Daniel D. A2 - Scheurer, Danielle B. PY - 2017 T2 - Principles and Practice of Hospital Medicine, 2e AB - Midway through a wound debridement, the scrub nurse noted that the sterilization indicators had not changed colors (indicating an inadequate sterilization process). A subsequent root cause analysis revealed that the sterile processing technician, at the end of his shift, forgot to push the button to start the autoclave. The next arriving technician did not notice that the sterilization indicator on the cart had not changed color, so he took the cart with the unsterile trays, and placed them on the shelf for use. SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/03/28 UR - accessmedicine.mhmedical.com/content.aspx?aid=1137605983 ER -