The national investigation
We have launched an investigation into the decontamination of surgical instruments.
All re-usable surgical instruments must undergo a decontamination process including washing, cleaning, disinfection, inspection and sterilisation before they are safe to use on a patient. Incorrectly decontaminated instruments increase the potential for cross contamination and infection of patients from residual organic material which has not been removed during the decontamination process.
This investigation seeks to explore what systems are in place to manage the decontamination process and prevent incorrectly decontaminated surgical instruments from being used on patients.
The reference event involved a woman who underwent a procedure to remove a kidney stone. During the procedure, ‘black’ material was seen to exude from a small tube contained within the surgical instrument. The procedure was stopped and the ‘black’ material was recovered and sent for analysis, which identified it as dried blood. The patient was tested for blood borne viruses, which were negative, and has not developed any symptoms since the procedure.
This national report focuses on the following themes:
- The role of system level risk and quality management systems in providing assurance within sterile services
- The focus on decontamination during the design process of surgical instruments
- The training requirements for sterile services staff to undertake decontamination of surgical instruments.