Dealing with Instrument Contamination and Speaking Up

When I began my career as an OR nurse, I did not fully understand the processes of decontamination, sterilization, and contamination, so I relied on my preceptor’s expertise. Fortunately for me, my mentor was a strong patient safety advocate. This article discusses instrument contamination, how to deal with contamination, and tips for speaking up about contamination.

Contamination

There are numerous reasons why instrument trays or peel-packed instruments are considered unsterile (Sidebar 1). Throughout my career as an OR nurse, I have witnessed many different types of contamination of sterile instruments and have had to defend my reasoning as to why a sterile table needed to be re-established due to instrument contamination. You may think that I was challenged by surgeons, but unfortunately, there were times that it was my colleagues to whom I had to show proof as to why a tray or item was considered unsterile.

Sidebar 1. When Sterilized Items are Unsterile

• Hole in the wrapper
• No chemical indicators
• No filters
• Organic material on an instrument (ie, hair, blood, bone, tissue)
• Bone cement on an instrument
• Unexpected items in the tray (eg, pens, cleaning brushes)
• Failed biological indicators
• Instruments are clamped closed
• A sterile package falls on the floor
  

Just recently, one of the surgical technologists at my facility found a hair in a sterile tray. Would you consider this tray to be sterile? If you answered no, you are correct. If it is not clean, it is not sterile.¹ The day that this occurred, there were a few team members who believed that the tray could be used. Our lead tech from the sterile processing department gave the perfect analogy: “You are eating at a restaurant, and I place this ‘sterile’ piece of hair into your salad. Would you remove it and keep eating?” Everyone shouted no.

Why is “sterilized” dried blood, bone, tissue, bone cement, or hair found on an instrument or in a sterile instrument tray considered unsterile? Instruments that were not properly cleaned prior to the sterilization process cannot be considered sterile because the dried material on the instrument can compromise the efficacy of the sterilant or its ability to reach all surfaces of the instrument.^1-4 If these items are used, they could pose a risk of infection to the patient.³

Most of the challenges I have encountered were about the integrity of the entire tray when only one instrument in the set was contaminated. If any instrument (eg, one, two, three) is contaminated, it means the entire tray is considered contaminated. I have had staff and surgeons say, “Just remove that item and we will be fine.” According to AORN, when a contaminated instrument is found in a set, the entire tray is contaminated.⁴

How to Deal with Contamination

When your surgical field has been compromised due to a contaminated instrument(s) before the procedure has started, you should immediately notify the team in the room and call the sterile processing department to have new instruments and supplies sent to the room. Then, you should begin breaking down the compromised field and recreating a sterile field with all new sterile supplies and instrumentation.

If the contaminated instrument is found after the case has already started, you should notify the surgical team immediately. The next steps include:

• Removing the compromised instrument and all items that have come in contact with it from the sterile field.⁴
• Having all team members who have touched the contaminated items change their sterile gloves.⁴
• Discussing with the surgeon the wound classification and if additional antibiotics will be given.
• Completing an incident report after the procedure to allow for a review to determine the root cause.¹
  • If the contaminated item was used on the patient, the incident report will flag the patient so that the infection control team can monitor the patient for a surgical site infection.

Tips for Speaking Up

Speaking up in the OR can be very frightening, especially when you know that what needs to be addressed may cause a delay in the surgical procedure. You should remember to always use your surgical conscience and do right by the patient. I have been in situations where I spoke up and upset the surgeon; however, in almost every situation, the surgeon later thanked me for being an advocate for that patient.

In 2022, the System Perioperative Education Director at my facility completed a quality improvement project and training for surgical team members on assertive communication techniques, including the Two-Challenge Rule and Concerned, Uncomfortable, and Safety Issue (CUS) words.⁵ The Two-Challenge Rule indicates that you should assertively voice any concerns, such as a contaminated item, at least twice to help ensure that it has been heard. If you have a surgeon or a team member disagreeing that an item is contaminated, you can use CUS words; for example:

1. I am Concerned because I found dried cement on this rongeur.
2. I am Uncomfortable using this tray for the procedure because the tray has been contaminated by the unsterile rongeur.
3. It is a Safety issue. If we use this tray, the patient is at risk for a surgical site infection.

You should never be afraid to be the patient’s advocate.

References

1. Garcia-Houchins S. Is that instrument safe to use on a patient? OR Today. Aug 1, 2022. Accessed March 19, 2023. https://ortoday.com/is-that-instrument-safe-to-use-on-a-patient/
2. Quick Safety Issue 64: Ensuring critical instruments and devices are appropriate for reuse. The Joint Commission. February 14, 2022. Accessed March 18, 2023. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-64/
3. If it’s not clean, it’s not sterile: reprocessing contaminated instruments. Event Reporting & Analysis – Alerts. ECRI. April 11, 2017. Accessed March 18, 2023. https://www.ecri.org/components/PSOCore/Pages/e-lert041117.aspx 
4. Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2024.
5. CUS Tool – improving communication and teamwork in the surgical environment module. Agency for Healthcare Research and Quality. May 17, 2017. Accessed March 19, 2023. http://www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/cus-tool.html 

AORN Resources

AORN members can access:

• Contaminated Instruments Present Patient Safety Issues: The Role of the Perioperative Team - AORN Journal
  
• Instrument Cleaning Considerations at the Point of Use - AORN Journal
  
• Point‐of‐Use Instrument Cleaning and Steam Sterilization - 2022
  
• Surgical Instrument Decontamination: A Multistep Process - AORN Journal
• Guidelines in Practice: Instrument Cleaning - AORN Journal
• Guideline Quick View: Instrument Cleaning - AORN Journal
• Guideline Essentials - AORN
  

If your facility subscribes to eGuidelines+, you can access:

• Sterile Technique Guideline | AORN eGuidelines+
• Instrument Cleaning Guideline| AORN eGuidelines+