Errors in packaging surgical instruments based on a surgical instrument tracking system: an observational study

Abstract

BackgroundSurgical instrument processing is important for improving the safety of surgical care in hospitals. However, it has been rarely studied to date. Errors in surgical instrument processing may increase operative times and costs, and increase the risk of surgical infections and perioperative morbidity. We aimed to investigate the errors occurred in packaging surgical instruments.MethodsSurgical instrument tracking system in a central sterile supply department (CSSD) was used to collect the packaging data during January–August 2016 in the First Affiliated Hospital of Soochow University, Suzhou City, China.ResultsData on 33,839 surgical instrument packages were collected. A total of 398 (1.18%) errors occurred, including incomplete packages (n = 70), instrument missing (n = 77), instrument malfunction (n = 27), instrument in wrong specification (n = 175), wrong packaging tag (n = 8), box and cover mismatched (n = 14), wrong packing material (n = 15), indicator card missing (n = 6), and wrong count of instruments (n = 6). The highest error rates were observed among least experienced nurses (N1 level) and during the 16:00–20:00 time period (both p < 0.05). A relatively high error rate was detected in the Department of Orthopedics as well as in the Department of Gynecology and Obstetrics.ConclusionWrong instrument specifications were the primary packing error identified in the current study. Further effort is needed to standardize the packing procedure for instruments under the same category and more effort is required to reduce the error rate during high risk times, or in the surgery department.

Armazenamento de produtos para a saúde estéreis, sistemas de barreira e sustentabilidade do meio ambiente

“…materiais limpos e sujos no setor de armazenamento (Oliveira et al, 2014), especificação errada, falta de instrumentos, pacote incompleto (Zhu, Yuan, Li & Cheng, 2019), todos esses elementos provocam a necessidade de um novo processamento, aumentando o consumo de sistemas de barreira estéril.…”

“…O consumo de sistemas de barreira estéril além do previsto, com base nos estudos analisados, se explica em função de uma série de falhas em diferentes fases do processamento tais como o acondicionamento, a inspeção, além do armazenamento em si (Oliveira et al, 2014;Kurniawansyah et al, 2015;Mussel et al, 2017;Nunes et al, 2019;Zhu et al, 2019;Tipple et al, 2020).…”

“…Outros elementos relativos ao fluxo e condições de trabalho na CME surgiram como resultado de alguns estudos, embora não se constituíssem no objetivo primário dos mesmos. Aumento da taxa de erros em pacotes no horário entre 16 e 22 horas (Zhu et al, 2019), 605 diferentes causas de retrabalho na CME (Alvim & de Souza, 2018) permitem inferir sobre o cansaço dos profissionais da CME e a necessidade de melhorias nas condições de trabalho reduzindo a possibilidade de falhas nessa unidade.…”

Risk factors for incorrect surgical count during surgery: An observational study

“…(Table 3). A recent study investigated the errors in packaging surgical instruments and found that most errors occurred from 4:00 to 8:00 p.m., when a large number of surgical instruments need to processed of in the central sterile supply department (Zhu et al, 2019). Thus, it makes sense that a majority of operations are performed in the morning when the nurses were focused with full energy.…”

Streamlining workflows and redesigning job roles in the theatre sterile surgical unit

“…Cleaning surgical instruments after each surgery removes existing blood or tissue, while sterilisation prevents the spread of diseases by bacteria or other pathogens 1. Studies have shown that the average rates of error in packing surgical instruments are around 1%–3% 2 3. Although there is no conclusive evidence of these errors leading to detrimental patient outcomes, complications resulting from the delays may have a negative impact on surgeries.…”