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