Rigid Containers

[Carol Forrest]

I wanted to give everyone a heads up on a near miss that occurred in our department. A Genesis rigid container was sent back to Central Sterile Processing on top of a case cart (standard procedure for our hospital) and by all appearances it was thought the tray had not been opened. The white lock was in place on both ends of the container. Later when the tray was needed, the staff member removing the tray from the shelf felt the tray was labeled incorrectly due to the weight of the tray. The tray was opened and found that is had been used. Fortunately the error was caught prior to the tray returning to the OR for use.

In our investigation we found that the Genesis locks frequently do not fall out of place once they are broken and the locks can appear intact if the lid is reapplied. Actions that we have put in place include: 1) Staff must physically pull on all of the locks on rigid containers returning to CSP to check their intactness 2) Staff have been reminded to use the designated locations for Dirty and Clean items returning to CSP.

As we all strive to be the safest hospital system in the nation I wanted everyone to be alerted of the above situation. We thought that we had checks and balances in place to prevent such an error, but found that quirky things can happen. Fortunately it was caught before it became a catastrophic event.

[AshlyMG]

Actions that we have put in place include: 1) Staff must physically pull on all of the locks on rigid containers returning to CSP to check their intactness

We also do this at my location, as it is difficult to tell sometimes. There are also times we have found an arrow's "feathers" aren't open enough to catch so even though it just came out of the sterilizer and was never used, we have to resterilize it because technically you could open it and reclose it without breaking the lock.

[barry govenor]

:eek::eek:carol,

Thanks so much for the heads up. We use this system also and have noticed that trays are sometimes opened at one end with the arrows appearing to be not all that much disturbed.

We do keep a watchful eye, but strange things do happen. I plan on showing your story with our O>R> supervisor

Barry

[allis]

Another question about Rigid Containers: We attach two tags, one on each side of the container, where date, load number and sterilizer number are recorded. Many times technicians forget to put those tags before sterilizing the trays. What should be done when a tray is missing tags after sterilization? Should we reprocess the tray? Can we cook some tags on the next load and add them to the tray?

[sheper1]

You need to reprocess the tray. The tag are to show that the items went through the process for that load.

[allis]

You need to reprocess the tray. The tag are to show that the items went through the process for that load.
I have to disagree with you. If I have intact locks, the tray content will be sterile. Therefore, there will be no need to reprocess the tray. Who said the tag is to show the item went through the sterilization process?

[dennalynn]

What sheper1 is saying is that you need to have the tag with the load info processed through the same load that the tray went through or it is considered an unsterile tray. Processing a tag through another load and then putting it on a tray already processed is dishonest and could lead to other unsafe practices. What if a preprocessed tag was placed accidently on a nonprocessed tray? or someone decided that they could put a preprocessed tag on a tray where the locks were broken but the lid was not removed? A better practice is to redo the tray and not have any questions as to it sterility.

[allis]

What sheper1 is saying is that you need to have the tag with the load info processed through the same load that the tray went through or it is considered an unsterile tray. Processing a tag through another load and then putting it on a tray already processed is dishonest and could lead to other unsafe practices. What if a preprocessed tag was placed accidently on a nonprocessed tray? or someone decided that they could put a preprocessed tag on a tray where the locks were broken but the lid was not removed? A better practice is to redo the tray and not have any questions as to it sterility.
Nobody would put different inforrmation on the tag from what the load number, sterilizer number and date would really be! I probably didn't express myself clearly enough. Let me say it like this: I pull a load from a sterilizer and all the tags are missing. ( We affix stamps to the tags after sterilization.) However, all locks are in place. Why such a load should be reprocessed? Before we used to have tags that didn't change after sterilization! Just a small piece of card!
What if a preprocessed tag was placed accidently on a nonprocessed tray? The external indicators on the locks will show that the tray didn't go through the sterilization process. In my facility we use a piece of steam tape to attach the list to the tray. This piece of tape is also an external indicator for that tray.
...or someone decided that they could put a preprocessed tag on a tray where the locks were broken but the lid was not removed?
If a lock is broken, a tag won't hide that! Replacing a broken lock by a precooked one would be dishonest, but as far as a tag is concerned, I need to understand that better.

[dennalynn]

I see that you may have a different system than we do. Our locks don't have an indicator as to whether they were processed but our load tags do. And we also affix the load sticker before sterilization not after. Our style containers and processes are different than yours so maybe I would need to understand your process a little better to understand your exact question. And I apologize if I sounded accusatory-I did not mean to be at all-just throwing out possible negative senarios of preprocessing any part of a container sytem.

[sheper1]

The locks and tags we use both have indicator tag to let us know that tray went through a process we also stamp all our items before they go in the sterilizer.

[allis]

I Our locks don't have an indicator as to whether they were processed but our load tags do.
I don't think locks without indicators should be used on sterilization containers. How could we know if a lock was put on a container before or after sterilization?
Sheper1's method and mine are not too different, except that I stamp my trays after sterilization. The reason is because the company servicing my sterilizers said the stamps fall off and clog the drains.
My concern about missing tags remains. Please, help!