TY - CHAP M1 - Book, Section TI - Chapter 16. Standardization and Reliability A1 - Gitomer, Richard S. A2 - McKean, Sylvia C. A2 - Ross, John J. A2 - Dressler, Daniel D. A2 - Brotman, Daniel J. A2 - Ginsberg, Jeffrey S. Y1 - 2012 N1 - T2 - Principles and Practice of Hospital Medicine AB - Table Graphic Jump Location|Download (.pdf)|PrintCase 16-1:INADEQUATE STERILIZATION OF SURGICAL INSTRUMENTSMidway through the wound debridement, the scrub nurse noted that the sterilization indicators had not changed colors—the surgeon was operating with instruments that had not been properly sterilized. The 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 arriving technician on the next shift assumed the autoclave had finished the cycle, and not noticing that the sterilization indicator on the cart had not changed color, removed the cart with the unsterilized trays and placed them on the shelf for use. SN - PB - The McGraw-Hill Companies CY - New York, NY Y2 - 2024/03/28 UR - accessmedicine.mhmedical.com/content.aspx?aid=56192117 ER -