Risk modeling of errors in the surgical instrument cycle, insights into solutions for an expensive and persistent problem

• Published in: Perioperative care and operating room management 2023-09, Vol.32, p.100333, Article 100333
• Main Authors: Nichol, Peter F., Saari, Mark J.
• Format: Article
• Language: English
• Subjects: Human performance; Risk of error score; Sterile processing; Stressors; Surgical instrument cycle; Surgical instrument error; Visualization
• ISSN: 2405-6030; 2405-6030
• DOI: 10.1016/j.pcorm.2023.100333

•Surgical Instrument Errors are defined as defects in surgical instrumentation that are identified in the operating room due to inspection or use prior to completion of a surgical case.•Surgical Instrument Cycle which is the series of tasks from the time that a surgical instrument leaves a surgeon's hand after one case, undergoes sterile processing and returns to the OR for the next case by a surgeon.•The Surgical Instrument Cycle for simple instruments is complex and lengthy. In our system it involves 104 tasks.•Based on this modeling, strategies that reduce stress levels in the sterile processing space and technologies that minimize visualization errors by humans would significantly reduce the risk of Surgical Instrument Errors. There is a limited but growing body of research on Surgical Instrument Errors. Surgical Instrument Errors are defined as defects in surgical instrumentation that are identified in the operating room due to inspection or use prior to completion of a surgical case. These errors include, but are not limited to, broken instruments, missing instruments, bioburden contamination as well as packaging errors that compromise sterility. Previous studies have focused on bioburden detection methods, error reduction via decreasing the number of instruments on trays, application of lean principles and detection of errors in the OR though observation. What has been absent from all these studies is a comprehensive mapping of the Surgical Instrument Cycle which is defined here as the series of tasks that occur from the time that a surgical instrument leaves a surgeon's hand in the OR after one case, undergoes sterile processing and returns to the OR in a functional and sterile state to be used in the next case by a surgeon Definitive mapping of the Surgical Instrument Cycle will facilitate identification of the tasks at the highest risk for error. And identification of these high-risk tasks will be essential for the design and implementation of durable, data driven improvements in sterile processing. this study was based at a large university hospital campus with a single sterile processing facility servicing three surgical sites at two hospitals (Adult Hospital inpatient and outpatient and a Children's Hospital). Observations were conducted in the following four spaces: operating room (Children's Hospital), sterile processing pre-washer or dirty side, sterile processing post-washer or clean side, and storage. The total number of tasks for simple