The United States Army perioperative nurses face unique patient care situations during overseas deployments. In this report, the experiences at the U.S. Army's 28 th Combat Support Hospital in Iraq are described. The lessons learned from these situations can assist in patient safety in future operations. The challenges to the nursing staff of performing "housekeeping" tasks while simultaneously accomplishing a number of other patient care tasks are reviewed. The surgical suite structural requirements for the operating room (OR) and for central materiel service (CMS), and the adaptation of the workflow capabilities through CMS to ensure the best possible sterile products are discussed. Cleaning becomes very difficult in deployed environments because of the mass casualty episodes as well as the relentless wind and sand. The effects of fatigue, sleep deprivation, and stress threaten maintenance of standards and attention to detail. Steam sterilization and glutaraldehyde soaking are useful as sterilization methods when adapted to this harsh environment. With this environment, it was necessary to extend the length of sterilization times, adapt pressure bags to rinse lumens, and realign the work flow to ensure better cleaning and sterilization practices. Cultures of the OR and CMS demonstrated the efficacy of our efforts. Room air exchanges, temperatures, water quality, and other structural requirements were measured on a routine basis and problems were aggressively addressed. The work and traffic flow practices were designed specifically to provide an aseptic environment and functional equipment. Staff safety and well being were given priority in order to maintain standards.