RT Book, Section
A1 Gitomer, Richard S.
A2 McKean, Sylvia C.
A2 Ross, John J.
A2 Dressler, Daniel D.
A2 Brotman, Daniel J.
A2 Ginsberg, Jeffrey S.
SR Print(0)
ID 56192117
T1 Chapter 16. Standardization and Reliability
T2 Principles and Practice of Hospital Medicine
YR 2012
FD 2012
PB The McGraw-Hill Companies
PP New York, NY
SN 978-0-07-160389-8
LK accessmedicine.mhmedical.com/content.aspx?aid=56192117
RD 2024/04/23
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.