| What is the biggest cause of errors in your instrument processing system? |
| People |
| human error |
| broken locks |
| lack of understanding the need to implement basic principles |
| communication |
| lack of training & comunication |
| Refusal of employees to take responsiblity for actions. |
| Human error |
| Not taking the time to get the correct information |
| Human |
| missing instruments |
| WRONG INSTRUMENT IN SETS |
| DECREASED PERSONNEL AND INCREASED WORK LOAD |
| Delivering instruments to wrong department. |
| incorrect count sheets |
| Losing instrumentation |
| Human mistakes via not paying attention |
| Not cleaning items properly |
| rushing |
| Incorrect instrument pick lists |
| instrumentation loss |
| communication problems with the OR |
| Lack of understanding by the technicians |
| scanning sterilizing load |
| PEOPLE |
| inadequate information from the vendors and manufacturers |
| workers not paying attention to the tray list and puting wrong instruments in set. |
| DAMAGE TO INSTRUMENTS, AND NOT DETECTED UNTIL AFTER STERILIZED |
| People not paying attention |
| Human-Lack of communication |
| none |
| Employees do not follow protocol |
| lack of time |
| time management |
| mislabeling |
| Lack of processing knowledge |
| Staff not paying attention to details, O.R. staff trashing instrumentation |
| Lack of attention by employee |
| Lack of Certification and Education |
| missing instruments |
| Inaccurate countsheet |
| distraction/interruption to the flow |
| Workload/staffing - error rates go up during high workload periods usually involving staffing issues also. |
| Not knowing how the instrument works |
| lack of concentration - human error |
| human |
| Efficient and effective follow through from staff members |
| Lack of naming standards |
| staff may not be as well informed on new technology |
| Making sure Instrument are Clean in Lockboxes,opening of Instrumentation and Lubation of Instruments. |
| rushing |
| communication |
| not be able to have the tool to clean with |
| during assembly wrong instrument in tray |
| going to the wrong process of repair |
| OR adding to sets |
| Time |
| lost items |
| Lack of training |
| people not caring about there job |
| communication |
| employees having to work to fast and making errors. Too big of a workload |
| not communication new instruments to be processed, to all shifts such as an "in-service," everytime. |
| Lack of communication |
| GETTING INTO BIG OF A HURRY |
| turn overs |
| not enough time |
| NO EDUCATION |
| not paying attention |
| the work load |
| careless |
| old way of doing things versus the "right" way |
| no enough information |
| Communication |
| i have no answer |
| lack of education |
| lack of knowledge on ph mixture with steam and soap |
| carelessness |
| cleaning |
| RUSH, rush, rush, everything is needed yesterday |
| Misreading information |
| human error/not paying attention/working too fast |
| CENTRAL SERVICE WORKERS OR SUGICAL TECHS THAT ARE NOT TRAINED ON PARTICULAR INSTRUMENTS |
| Not always having information on disassembly when instrumentation comes in as loaners |
| NOT FOLLOWING THE LIST |
| Lack of knowledge |
| Lack of specific info from Vendors |
| debree in suctions |
| techs do not want to be responsible for anything |
| rushing, trying to speed up the process, not listening to others |
| Surgery purchases new instruments/power equipment, no consideration for educating CS. |
| lack of knowledge |
| Instruments that are outside the generic cleaning procedures |
| Specific cleaning process for instrument. |
| the OR |
| Oversite. Inexperienced employees. Heavy work load. |
| Manufacturer guidelines that do not follow normal processing guidelines. |
| Instrument identification |
| Not concentrating on your work! |
| not getting the complete info from companys |
| Sterilization |
| n/a |
| not having enough instruments, & mixed metals |
| staff failure to follow procedures |
| identifying specialty instruments to prepare pictorial count sheet |
| short turn over time between cases/ enough sets |
| lack of communication |
| lack of knowledge of the instruments |
| MANUFACTURERS NOT HAVING ADEQUATE PROCESSING INSTRUCTIONS |
| time constraints |
| not checking the count sheet correctly |
| lack of inservice prior to use of the instrument |
| People hurrying trying to get all the sets assembled. |
| human |
| how and what to take apart |
| Personnel Handling and Carelesness |
| working with CSR staff / building a relationship they do our final proscess, in both departments departments are working together to make things better, which is working!! |
| lost instruments after procedures |
| Staff not using systems in place...going on memory |
| attentiveness |
| Lack of time |
| turnaround pressure |
| the Mfg instructions not being given to Sterile Processing |
| carelessness |
| Lack of education |
| In the Decontam Process |
| Incomplete Trays, Incorrect Instruments in Trays |
| no comment |
| distractions |
| not following manufactures recommendations |
| Employee laziness |
| somtimes people are not on the same page. |
| REPS. |
| lack of knowledge |
| Lack of knowledge |
| not communicating with the or |
| lack of good information |
| LAST INST. |
| lack of knowledge |
| people with no education |
| improper training |
| Inattention to details |
| communication |
| censitrac |
| Human |
| Communication between OR and SPD, ex. Adding on cases or taking trays from other cases leaving that case without a tray. |
| Staff not following protocol |
| the way the instruments is returned after use. |
| human |
| dirty |
| Miss labeling |
| Staff not knowing how to take apart some of the multipart equipment |
| 20 |
| Staff not paying attention to task |
| Not knowing how to take care of them. |
| Rushing |
| Rushing |
| new instruments that come without instructions on how to disassemble |
| not enough education |
| rust formation |
| lack of information or sharing information |
| People who are poorly educated or think they know everything |
| the o.r |
| lack of communication on recipe changes |
| LACK OF COMMUNICATION FROM THE O.R. |
| LACK OF INFORMATION |
| lack of knowledge |
| mislabeling of instruement sets |
| Handling them in the washers |
| misscount |
| Missing Instruments |
| humans |
| not enough instruments |
| not many errors in my hospital instrument processing is very well handled |
| human error |
| training |
| not knowing the instrument |
| MISSING INSTRUMENTS |
| confusion |
| dirty inst. found in the set |
| not paying attention |
| correct count sheets |
| human errors |
| care of instruments |
| Lack of education |
| Processor error |
| Technicians putting the set together by memory rather that using the count sheet. |
| working too fast |
| attitudes |
| low staff |
| communication |
| Staff being in a hurry |
| LACK OF kNOWLEGDE AND UNDERSTAFFED |
| knowledge |
| employees not paying attention to their work |
| not following directions |
| lack of knowledge |
| Lack of knowledge of the Surgery Staff |
| Missing Instruments |
| Innability to stay caught up due to instruments that need to be turned over. This does not allow us to start preparing for the following day. |
| not passing information to other shifts |
| instruments not being checked for cleanliness and then being put in a set to sterilize |
| Comunication |
| Staff not trained thoroughly |
| lost and missing instruments from surgery |
| don't provide the correct information on processing instruments |
| rushed staff |
| missing instruments from sets then to instruments that need repair |
| not enough instruments |
| loss of focus |
| people |
| persons not looking at information available to them |
| Failure to follow policy |
| lack of education |
| Lack of educational opportunities |
| Human errors |
| not following manufacturer instructions |
| People - Complacency |
| lack of information for processing instruments |
| handling |
| STERILIZATION |
| identification of wrought instrumentation |
| no training |
| having the right,and extra instruments on hand. |
| human |
| HUMAN ERROR |
| trying to do it from meomery |
| human error from not paying attention to details |
| human error |
| people not paying attention to what they are doing |
| lack of knowledge |
| not enough help |
| human |
| not enough speciality sets of insts. for operation procedures. |
| people |
| Uneducated staff. |
| Deviation from cleaning protocol |
| Wrong instrumentation in sets |
| When technicians become hurried and don't remain focused |
| vendors not providing information to systems that we have been using for years |
| not paying attention |
| timeing |
| processing |
| Communication |
| people not paying attention to the detail it takes in caring for the instrumentation |
| SALES REPS |
| MENTAL ERRORS |
| Placing the wrong instrument in a set |
| Human Error |
| NOT PAYING ATTETION |
| Being in a hurry |
| wrong sterilization instructions |
| Communication |
| INSTRUMENTS MISSING IN SETS. |
| unqualified personnel |
| hurry |
| missing inst. |
| incorrect count sheets |
| people are to big of a hurry to get the job done |
| people trying put trays together from memeris |
| Staff |
| lack of proper training |
| LACK OF COMMUNICATION |
| "lost" instruments between OR and CS |
| missing instruments |
| lack of knowledge |
| unfamiliar instrument sets |
| instruments not making it back to central sterile |
| Staff taking short cuts |
| human |
| staffing ratios per productivity |
| Loss of intruments |
| documenting instruments missing for OR |
| time, too little staff trying to work too fast to get the work done. |
| There is no system |
| Tech error |
| cleaning |
| LACK OF COMMUNICATION FROM THE O.R. |
| nurses not relaying information |
| being in to big of a rush not taking enough time |
| missing instruments |
| lack of communication between o.r. and spd |
| human error |
| rushing |
| lack of education |
| lack of not being certified, education |
| lack of information |
| inexperince staff |
| Staff's limited knowledge of how the instrument is used |
| damaged instruments |
| No dirty elevator for dirty case cart |
| Human Error |
| not having continuous education |
| lack of knowledge of instrument in trays |
| DECONTAMINATION |
| Not following count sheets consistently and staff not knowing the instruments |
| old equipment that breaks down all the time |
| miscount |
| none that I know of |
| Lack of consistency in education and training |
| the person not knowing what they are doing |
| lack of proper instrument handling |
| HURRIED PROCESSING DUE TO INCREASE IN CASES/LACK OF STAFF |
| loss |
| lack of attention |
| Communication/Lack of education |
| Low Staffing |
| staff taking short cuts in processing |
| Turn around time for next case. One tray back to back use. |
| under education |
| the need to turn over inst.makes for mistakes |
| not having enough staff |
| inattention |
| employee error |
| cleaning processing. |
| communication |
| untrained personnel |
| Not following instructions |
| LACK OF TIME TO REPROCESS |
| Human Error |
| lack of proper training |
| Standardization of names. A mixter can have as many names as there are hospitals. |
| lost instruments |
| decontamination |
| Lack of comunication. |
| Human error, carelessness |
| People not focusing on their jobs |
| Lack of knowledge from reps |
| human error |
| surgical tech |
| Not receiving instrumentation from the user department in the manner in which CSP has requested. |
| lazy personnal |
| lack of instrument |
| lack of knowledge about the instrument |
| communication |
| instruments not cleaned properly |
| human resource |
| COUNT SHEETS /INSERVICE |
| Working too fast |
| not reading manual |
| poeple don't really care- they hurry and go way to fast |
| handling |
| no written instructions |
| assembly |
| lack of knowledge |
| forgetting to put a chemical indicators in and outside of the tray. |
| No universal regulations and practices practiced in both the OR and SPD departments |
| instruments bought without requesting cleaning and sterilization parameters. |
| Fine instrument breakage. |
| Human Error |
| Not paying attention to trays |
| Attention to detail and keeping up with current changes to OEM instructions. |
| rushing or working off memory |
| instrument count |
| Human error |
| shaort staffing |
| Communication |
| heavy workload for the amount of staff |
| low-level removal of visible bioburden process for forceps |
| EDUCATION OF NEW STAFF |
| inst getting lost or misplaced |
| FAILURE TO FOCUS |
| MUILTPLE VENDORS FOR SAME TYPE INSTRUMENTS |
| lack of knowledge |
| not receiving the entire instrument from the OR |
| people with no knowledge |
| discolored tape and several people assigned to the processing area that are not as familiar |
| people not paying attention to what they are doing |
| disinterested personal |
| new personel,not using new inst.much |
| Maintaining staff with experience. We are often seen as an entry level area of the hospital as many persons are seeking careers in the healthcare field. Unfortunately we have not yet been elevated to the level where CS is recognized as a career. |
| human |
| no education, comunication |
| proper handling from surgery |
| not having the right information |