What action to take when finding moisture in boxes of sterile instruments after patient incision

What is it about?

The fact is that moisture in boxes of sterile instruments raises doubts about the sterility of these instruments, making them theoretically unusable. This situation calls for the precautionary principle to be put into practice by stopping the intervention forthwith, with the consequence that the patient’s anaesthesia, and possibly even the operation itself, will be terminated, and that reintervention will be necessary, thus inevitably increasing the risks of anaesthesia and infection.

This Patient Safety Solution is intended to suggest what to do when sterilisation packaging is found to be wet or moist during the course of an intervention, after patient incision, and in the absence of other immediately available and usable sterile instruments.

This patient safety solution concerns all professionals in the operating theatre.

Method

This situation has come to light through the spontaneous reporting of adverse events encountered by surgeons from the approved accreditation body for orthopaedic and trauma surgery. In 2009, a survey was sent out to the physicians declaring an adverse event pertaining to sterility defects in intraoperative instrument boxes, in order to allow an understanding of the general dysfunctions related to this situation.

In 2011, the analysis of the feedback database for the doctors and medical teams accreditation system allowed the identification of 2212 declarations pertaining to a risk related to a modification of an intervention due to functional failure, unavailability or lack of sterility of equipment.

Moreover, a literature search has been conducted by the approved accreditation body.

Risk reduction tools

The adverse events in-depth analysis proposes actions to take when finding moisture in boxes of sterile instruments after patient incision :

• A decision tree summarises the approach to take in this at-risk situation.
• Actions to take after an occurrence has been identified.