The Healthcare Safety Investigation Branch (HSIB) released a report on the decontamination of surgical instruments in NHS-funded care across England. The report highlights the importance of proper decontamination procedures to ensure patient safety and prevent the spread of infections. In this article, we will discuss the key findings of the investigation, safety observations, and suggestions for improvement.
Background
The investigation focuses on the work of sterile services departments (SSDs) responsible for the decontamination of surgical instruments. The report highlights the complexity of the decontamination process and the potential for errors to occur at various stages, including cleaning, disinfection, and sterilization. The investigation also identified several patient safety concerns related to the decontamination of surgical instruments, including the risk of infection transmission, inadequate training and supervision of staff, and insufficient monitoring and reporting of incidents.
The Reference Event
A 56-year-old woman had a kidney stone and chose a procedure called percutaneous nephrolithotomy (PCNL). During the surgery, doctors found dried blood in her kidney because the reusable surgical equipment wasn’t cleaned properly – some crucial brushes were missing. They stopped the procedure and successfully used another method to remove the kidney stone.
Fortunately, despite being exposed to the dried blood, the woman tested negative for blood-borne viruses. An investigation revealed that the operating room staff didn’t fully understand the importance of the missing brushes, pointing to problems in how they clean and communicate about equipment. The decision to use the equipment, the only set available, was influenced by a lack of proper safety checks.
Key Findings
The investigation identified several key findings related to the decontamination of surgical instruments:
Inadequate training and supervision of staff
The report found that many SSDs lacked sufficient training and supervision of staff responsible for decontamination procedures. This led to inconsistencies in the quality of decontamination and increased the risk of errors and infections.
Insufficient monitoring and reporting of incidents
The investigation found that many SSDs did not have adequate systems in place to monitor and report incidents related to decontamination procedures. This made it difficult to identify and address issues on time.
Lack of clarity in roles and responsibilities
The report identified a lack of clarity in roles and responsibilities among staff responsible for decontamination procedures. This led to confusion and inconsistencies in the decontamination process.
Safety Observations
The report also includes several safety observations related to the decontamination of surgical instruments:
Reporting incidents of incorrectly decontaminated surgical instruments
The report suggests that it may be beneficial for SSDs and operating theatres to report all incidents of incorrectly decontaminated surgical instruments nationally. This will help the healthcare system understand the resulting patient safety risks and issues.
Adoption of standardized risk management systems
The report suggests that it may be beneficial to consider the adoption of standardized risk management systems across NHS trusts. This will help ensure consistency and standardization in the decontamination process.
Clear lines of accountability for SSDs
The report suggests that it may be beneficial to define clear lines of accountability for SSDs, including services provided by NHS trusts and contracted services. This will help ensure that all staff understand their roles and responsibilities in the decontamination process.
Review of the decontamination process during instrument design
The report suggests that it may be beneficial to review the process that assures that decontamination of surgical instruments is appropriately considered during the design of surgical instruments. This will help ensure that instruments are designed with decontamination in mind.
Cleaning internal surfaces of tubes
The report suggests that it may be beneficial to include a process for cleaning the internal surfaces of tubes (lumen) by use of an ultrasonic bath and confirmation clear by high-pressure air (where this is not specifically excluded by the device manufacturer) in addition to the requirements set in the manufacturer’s instructions for use.
Suggestions for Improvement
The report makes several suggestions for improvement to reduce the risk of harm to patients:
Develop a competency framework for all sterile services staff
The report recommends that NHS England and NHS Improvement develop a competency framework that defines the skills, qualifications, and professional registration required for all sterile services staff. This will ensure that staff are adequately trained and supervised to perform decontamination procedures.
Define ‘top management’ and its commitment to quality
The report recommends that Health Technical Memorandum 01-01 be amended to define ‘top management’ and its commitment to quality. This will ensure that all staff understand their roles and responsibilities in the decontamination process.
Report external independent audits directly to the responsible executive director
The report recommends that external independent audits be reported directly to the responsible executive director in a trust who is accountable for the service, not just the certified department. This will ensure that incidents related to decontamination procedures are identified and addressed on time.
Conclusion
The decontamination of surgical instruments is a critical component of patient safety in healthcare. The HSIB report highlights the importance of proper training, supervision, and monitoring of staff responsible for decontamination procedures. By implementing the safety observations and suggestions for improvement outlined in the report, healthcare systems and processes can be improved to reduce the risk of harm to patients and ensure the safety of surgical instruments.
Reference
- Decontamination of surgical instruments. (2023, October 4). HSSIB. https://www.hssib.org.uk/patient-safety-investigations/decontamination-of-surgical-instruments/investigation-report/#the-reference-event
- Decontamination of Surgical instruments Independent report by the Healthcare Safety Investigation Branch (May 2022)
