Hospitals are continuing to run afoul of The Joint Commission (TJC) accreditation inspectors for equipment that has been improperly sterilized or subjected to insufficient high-level disinfection (HLD).
“From 2013 through 2016, Joint Commission immediate threat to life (ITL) declarations directly related to improperly sterilized or HLD equipment increased significantly,” TJC recently reported.1 “In 2016, 74% of all ITLs were related to improperly sterilized or HLD equipment.”
The most frequently cited TJC standard in these inspections is Infection Control (IC) 02.02.01, which calls for facilities to protect patients from infections cause by inadequately processed equipment.
“[T]he most vulnerable locations for lapses in sterilization or HLD of equipment are ambulatory care sites, including office-based surgery facilities, and decentralized locations in hospitals, even though the data shows higher noncompliance rates for critical access hospitals and hospitals,’’ TJC states.
Common lapses in TJC surveys include:
- insufficient training in sterilization and HLD equipment.
- Lack of leadership oversight
- Recommended protocols are undermined by “shortcuts”
- No designated staff member assigned to sterilization and HLD
- Facility design or space issues prevent proper sterilization or HLD of equipment
Questions you may be asked during a survey
- How often do you assess for staff competency? How are managers/supervisors deemed competent? Where are documented competences kept?
- Show me the instructions for use of the sterilizer, the endoscope, or HLD.
- Show me the evidence-based guidelines for HLD and/or sterilization.
- Show me the documentation logs for HLD and/or sterilization. Are they complete? Are there gaps?
- Is there enough storage provided to store endoscopes? Are there enough surgical instruments to minimize the use of immediate-use steam sterilization (aka “flash” sterilization)?
- Joint Commission. Improperly sterilized or HLD equipment – a growing problem. Quick Safety 2017;33: http://bit.ly/2qUn8q1