Common deficiencies

What are the common deficiencies identified?

  • Inappropriate product is used to clean reusable medical devices during the cleaning step—the product must be a detergent and not a disinfectant product
  • Reusable cleaning accessories are not cleaned and sterilized between uses (or disposable cleaning accessories should be used and discarded daily)
  • Biological monitoring is not being performed
  • Internal chemical indicators not being placed in each package for sterilization
  • External chemical indicators not being placed on the outside of each package for sterilization
  • Sterilization monitoring parameters (physical, chemical and biological) are not documented
  • Inappropriate wrapping materials and tape used for packaging equipment for sterilization
  • Personal protective equipment is either not available or not worn by staff when reprocessing
  • The manufacturer’s instructions for reprocessing medical devices are not available
  • Reprocessing is occurring in patient care areas with patients present
  • Documented policies and procedures are not developed for all steps of reprocessing and training procedures for reprocessing staff

Levels of risk to the public

Legislated requirement

  • Failure to meet requirements outlined in relevant acts or regulation (e.g. Occupational Health and Safety Act)

High risk

  • Immediate health hazard exists—stop practice and correct immediately
  • The act or failure to act immediately may lead to the transmission of infection or risk of illness or injury
  • Practices that cannot be corrected immediately must be stopped until the health hazard is observed to have been eliminated

Medium risk

  • Signifies practices that must be corrected—timelines for compliance or agreement on alternate process determined through consultation with the program or during assessment
Monitoring, documenting and maintaining your steam sterilizer
How to carefully clean and package reusable medical devices
Prepare for the assessment or use this on an ongoing basis to stay on top of best practices