The 2 times we delivered contaminated sets to the OR were 2 times too many. We were fortunate that no patients suffered infections, but we realized we had to improve the coordination and communication between the ORs and the sterile processing department to ensure unsterilized instruments never again reached the sterile field. We came up with a standard sterility verification method to confirm the sterility of instruments in wrapped instrument trays or rigid sterilization containers. Here's a step-by-step guide to how you can implement our checkpoint method, which we call the "Four-Five Points Check" system, so named because OR and SPD staff members verify the sterility of instruments multiple times by checking sterilization indicators in wrapped trays or rigid containers. OSM

1. SEVERAL LOOKS The program centers on a 4-point check of wrapped instrument trays and a 5-point check of rigid instrument containers. We added both sets of checklists to instrument count sheets — a line for each that staff members in SPD and the OR must complete — for easy reference and consistent application. Now staff members in both areas sign off that they've confirmed each item on the checklists.

2. PROPER PLACEMENT SPD staff members lay a chemical integrator at the bottom of wrapped trays or rigid containers and tape another integrator to the instrument count sheet, which is placed on top of the instruments. They sign the count sheet and wrap the tray or close the container. The load locator barcode and/or indicator stamp is affixed to the outside of the wrap or container before it's put in the autoclave.

3. OFF THEY GO A member of the SPD staff completes the 4- or 5-point check, as appropriate, for each load of sterilized instruments before they are placed in case carts for transport to the ORs.

4. SURGICAL CHECKPOINT Once the instruments reach the OR, the circulating nurse and scrub tech use the 4- or 5-point check when setting up a room to confirm that the sterilization indicators have turned the correct color and that load locator barcode stamps are present.

5. NO HARM DONE The circulator or scrub tech check rigid containers and wrapped instruments to ensure the integrity of both remains intact. If the tape on wrapped trays is torn, the instruments are immediately returned to the sterile processing department. Our goal is to fully convert to using rigid sterilization containers within 2 years. In the meantime, we place autoclavable rectangular plastic trays and rubber tray protectors under wrapped instrument trays before loading them into the sterilizer, to prevent perforations and tears.

6. TIMEOUT TOPIC Confirming instrument sterility during pre-op briefings has been one of the key steps to making the program work. The OR team confirms that 4- or 5-point checks have been completed and the scrub person holds up the chemical integrator strips so the team can visually verify that they changed color.

7. EASY IDENTIFICATION The circulating nurse scans the load locator barcode stamps on all instrument trays, so we can match individual sets to specific sterilization loads and procedures. We also document completion of the 4- or 5-point checks in our electronic medical records.

8. RETURN TRIP At the end of each case, the surgical team places the count sheet in with the dirty instruments and loads them into a case cart. The cart is wheeled back downstairs to the sterile processing department, where the sterilization process and check point system begin anew. For more than 3 years since we implemented the program, the sterile processing manager sent all count sheets to the quality improvement manager for data analysis. The reports showed 100% compliance with the 4- or 5-point checks, so, as of last year, we no longer submit collected count sheets for analysis. However, staff members in the OR and SPD continue to monitor their performances.