Broken Container Locks

[dbunn]

I caught one of my technicians replacing a broken lock on a container from a bag of locks which had been sterilized just for this purpose. When I informed him that he could not do this, he wanted to know why. He told me that as he was pulling the load out of the sterilizer, he noticed that one of the locks on a container was loose and subsequently fell off. Since the tray was not opened and never left his sight,(was still on the sterilizer cart) he felt that it was OK to replace it lock, taking care not to open the lid. I have since interviewed many people from different hospitals only to hear that this practice may be routine. I would like to know from others, if this practice is ok and if so under what circumstances.

[CSS TECH]

I caught one of my technicians replacing a broken lock on a container from a bag of locks which had been sterilized just for this purpose.
Who sterilized the bag of locks for that purpose? Is it the department or the technicians did that secretely?
If the lid was not removed, I don't think there should be any problem replacing the lock. Remember that your technicians are in charge of sterilization. They should be able to make decisions in a circumstance like this.

[dbunn]

I don't know who sterilized the locks, but found out that this practice has been in place years before I started here. It wasn't done in secret, but not advertised either.

[Harvey Johnson]

OOhh, man this thread opens a trick box...
This is one of those "don't do it" (but everybody does).
My first few weeks in the department, I found one bag of cooked locks and tossed them letting people know it is not accepted practice, expaining having them available only promotes carelessness and could easily be misused.
That action and talk lead to improved practices..... they became much more improved at hiding and using the cooked locks.
So I guess it's a matter of education and trust, keeping in mind you have to trust your weakest link to only bring out the cooked lock when a situation arises such as dbunn pointed out.

[citylmt7]

what would JCAHO say about finding a bag of "cooked locks"?

[Robert Corley]

I would just take the extra two minutes it would take to redo the tray. I would not take the chance of sending a dirty instrument tray over to surgery. The way i would look at things are like this: What if i was having surgery and that tray was going to be used on me, or someone in my family. Sterilizied locks i would throw away and just redo the tray. That is how we do it here in Myrtle Beach, SC

good luck to you and I hope i helped.

[CSS TECH]

I would just take the extra two minutes it would take to redo the tray. I would not take the chance of sending a dirty instrument tray over to surgery. The way i would look at things are like this: What if i was having surgery and that tray was going to be used on me, or someone in my family. Sterilizied locks i would throw away and just redo the tray. That is how we do it here in Myrtle Beach, SC

good luck to you and I hope i helped.
I don’t see why the tray has to be redone. If the tray is dirty only because the lock is broken, it will still be dirty with an unbroken lock in place. A broken lock does not annihilate sterility, unless the lid of the tray was displaced.
I think each lock would have a number if it were inappropriate to replace a broken lock after a tray is sterilized.

[Robert Corley]

Well here we use the additive, when in doubt throw it out. we treat a broken lock as if the tray is unsterile. so then we redo the tray and resterilize it. just so we leave nothing to chance. it doesnt take that much longer to redo. better safe than sorry.

robert

[sunshine]

Wow....never heard of such a thing! The items would be considered not sterile here.....nothing in between. Why are locks breaking?

[CSS TECH]

A broken lock does not annihilate sterility, unless the lid of the tray was displaced.
If a tray is found on the shelf with a broken lock, it will be considered unsterile. If a lock is broken while a tray is being pulled from the sterilizer, the lock is replaced! SPD technicians are in charge of sterilization. Why are locks breaking is another question! Are locks used to prevent contamination? Nooooo! We need to reconsider our perception of the locks used on trays. They are not there to lock doors to forbid access to microorganisms!

[David Freeman]

The purpose of the lock is to assure that the lid has not been removed since the tray underwent the sterilization process. If the practice of replacing a broken lock with a pre-cooked one is allowed, no matter how careful, then the purpose of the lock as stated above is invalid. If you allow it if the technician noticed the broken lock and knows for sure that the lid has not been disturbed, how about if the handles have been popped but the lid not removed? How about if the lid was opened just a bit because the tech didn't remember if he put an integrator in the tray and he didn't want to get in trouble so he checked and then put the lid back on along with a pre-cooked lock?

I know it's a slippery slope argument but I know busy people will take short cuts when they think they can and SPD is no place for short cuts. The patient on the table is trusting us to do it right, every time.

As for the question "what would JCAHO say about finding a bag of 'cooked' locks?" I would ask, what is your administrator going to say to the SPD manager who allows the practice after he gets a Type I?

[chipmoore]

One suggestion, read the CRCST Self Study Series in the January/February issue of the Communique, subject "Implementing a Quality Management System", pages 36 to 39. Check component #3. You might find an answer to the broken container lock question.
Chip Moore
Rochester, NY
Retired but Involved

[Harvey Johnson]

Back to the subject of the cooked locks.....
Do we have a policy regarding compromised security locks? Yes.
Are department people educated as to patient safety outcomes and the consequences of violating policy? Again, yes.
To me, trust is the key.
Not being omnipitent enough to be everywhere to see everything 24/7 I have to be able to trust tasks are being completed according to policy.
The question "what would you do if it is someone you know on the table?" is a constant reminder.
Everyone on my staff is aware if I can't trust a Tech to have the common sense to do the right thing at the right time or ask when in doubt, they are history.
I haven't seen or heard of cooked locks in four years, so I believe (read hope) people have received the message.

[dbunn]

I'm glad to see so many responses to my question. I think that this is one of those practices which needs to be brought out into the open. I also feel that the decision should be based on scientific evidence. It appears that if a tray is discovered on the shelf, in the OR, etc. there's no question, the tray is redone, rechecked and all indicators replaced. For those which answered, I would just take the few extra minutes to redo the tray, suppose the tray was one of a kind and needed for surgery in a few minutes. Suppose you witnessed the lock falling off, and also felt confident that the lid was still intact? Then what would you do if you knew that the case was going to be delayed by hours waiting for the tray to be resterilized? A locking falling off in of itself does not contaminate a tray. Comments?

[dbunn]

I'm not advocating the replacing of missing locks from trays. I've always felt that under no circumstances should anyone ever do this. However, it appears that the practice is widespread and therefore needs to be addressed. I've been told that there are hospitals which do address this in their policies stating that it can be done under certain circumstances. I have not found where anyone is replacing locks on trays which were found in storage, came from the OR, etc. or other situations when it's questionable.

I also feel that this practice will continue at many hospitals, not here, until there is scientifice evidence which supports why it should not take place. Scrub techs are trusted to determine when contamination takes place in their room and rectify if. Are CSP techs not capable of deterimining when something is contaminated? Of course when in doubt, correct it, but what I'm hearing is that the techs do not believe contamination has taken place because the lid remains intact and never left their sight.

Please excuse me, I'm taking a research course so I want to see the scientific evidence which supports this practice or the discontinuation of it. Who wants to do a study?:)

[CSS TECH]

Spd, Robert, Sunshine, David and Chipmoore, I heard you all. I listened to you with great attention. Companies selling the locks specify those locks should not be pre-sterilized, and I am wondering why those companies don’t manufacture the locks in a way that they become disabled after they get cooked!
Now, let’s move the discussion to another level. Many locks that are approved for rigid sterilization containers do not have an indicator/integrator. How could that be compatible then with the general perception we have of those plastic locks?
It’s only recently we started thinking of those containers in my facility. Wrapping in KimGuard has been the standard for many years there. And without all the insights I received from this thread, my first choice of rigid containers was a company that provides an “intelligent locking system” called Thermoloc. This system “eliminates the need (and cost) for the plastic locks/arrows required on other container systems. It is a red bar that is heat-activated to automatically come down during the sterilization cycle and lock the lid latch in place. The container remains sealed until opened in the O.R. Once the red bar is reset, it will not come back down unless the container is sent through the sterilizer again. This ensures that the container has not been opened prior to it arriving in the O.R., providing a true tamper-evident seal.”

[dennalynn]

A good subject for discussion. In addition to the concerns many have already raised I would also be concerned that the pre-cooked locks get placed on a container that HAS NOT been sterilized and that container is mistaken for being sterile because the locks are indicating a sterile tray.

[sunshine]

Sounds like a good choice CSSTech. We are stuck with what we have for a few years. Manufacturer must be listening.
The type of containers we have, the locks don't dangle. If the lock is broke the lid would have had to be comprimised......by the latch being opened.
I haven't worked alot with the dangling type locks but saying that....if we had this problem...locks breaking....we would be in contact with the manufacturer to improve them or change the way we handle them.

[wperez]

I am sorry but to allow your technicians to sterilize locks in case a lock is broken off is ABSOLUTELY the wrong thing to do. You as a patient advocate resterilize all trays when integrety is compromised. We inspect all trays when we removed them from cart to cart to make sure that we did not break any locks in handling. We follow best practice and reprocess the tray. When in doubt throw it out! Do you cook dart test, indicators, load cards in case you forgot as well?

[Harvey Johnson]

wperez puleeez, let's not hurt ourselves jumping to conclusions.....
I know you are sorry, but why try to toss gasoline onto the fire, where do you read in the above postings any of us said we "allow" this practice? That would be professional suicide. We all agree this is not an allowed practice and in that we are not present 24/7 we have to trust all procedures are performed to the standards and practices of our respective departments. Now if you possess the perfect solution for this conundrum, please share it with the rest of us, we want to be perfect also.....

[wperez]

I'm not suggesting anyone allows this behavior. It is so important for all of us to do the right thing everytime. We have to keep in mind why we do what we do. Sterilization is critical to the outcomes of our surgical procedures. We can't and shouldn't take shortcuts. In the postings above I read in certain situations you feel it is appro[riate to replace broken locks and I say it isn't. A difference of opinions perhaps. I am far from perfect however I provied my associates with best practice recommendations and would never permit locks to be presterilized. I also agree that SPD is no place for shortcuts, take the time you need to do your job to the best of your ability following AAMI guidelines and you can't go wrong.

[Harvey Johnson]

"I read in certain situations you feel it is appro[riate to replace broken locks"
Not sure where in my postings on this thread you were able to come to the conclusion I found the practice "appro[riate".
I believe I stated clearly, it is not.
Face reality, all the policies, procedures, AAMI guidelines, JCAHO reviews in the world will not keep some people from using shortcuts if they think they will not be held accountable.
It is our job to insure people with that attitude will be held accountable and quickly find themselves looking for another line of work.

[cpdguy]

Well, as they say "this is a deep issue". The issue is a practice issue. Not just a broken lock issue.

Having a bag of locks that have been sterilized in advance is poor practice and promotes poor practice.

"It has never left my sight", so if the lock breaks when placeing on the wire rack do we put a "new lock " on it becasue it never left my sight.

Poor practice promotes poor practice.
Broken lock means redo. That simple.

Yes the technician need to be able to make on the spot decesions. It should be why did it break ? Over loading,poor loading technique, not put on correctly the first time,poor locks? The bigger question is how long has this been going on?

I would never allow this. It is just poor practice. This raises the question what else " do we have in bags" when something goes wrong.

Just my two cents.

[chipmoore]

Maybe it's my medical device Mfg background/experience, but I like root cause analysis. I just went back and read all the post. Has anyone considered filing a broken container lock product complaint with the FDA? In my view, a broken lock after a sterilization cycle is a defective product and corrective action by the device Mfg is recommended. The container and lock is a system and the expectation should be it works each and every time by design. Why spend time writing policies to counter something you would expect to have good performance each day. Again, why are the locks breaking and what should be the corrective action so they don't "routinely" break?
Chip Moore
Rochester, NY
Retired but involved

[wperez]

Makes sense to me. I have used locks and arrows they all break. My concern is that we don't promate or support the replacement of locks with presterilized locks. Thanks for staying involved.

[Rod Brueggeman]

If you explain to technicians your reasoning for not allowing pre-sterilized locks they will understand. As someone posted earlier - by pre-sterilizing locks you have created an opportunity to put pre-sterilized locks on unsterile pans.

What do you do if you are wrapping trays and after sterilization you have broken indicator tapes? Do you have pre-sterilized indicator tape on stand-by or do you re-wrap and re-sterilize?

[walter r steiger]

In my dept. i will not send any thing out with locks on them ,i do not replace broken locks. i will pop the rest and re do
thanks walter