top of page

During a recent Joint Commission Inspection, a sterile processing tech made an unthinkable error, costing them their accreditation.

Sterile processing professionals play a crucial role in healthcare settings by ensuring that surgical instruments are properly sterilized and ready for use, which is vital for patient safety and the success of surgical procedures.

Despite their expertise and the critical nature of their work, there are common mistakes that can occur during the sterilization process.

Here are some of these mistakes:

1. Improper Cleaning and Decontamination: Instruments must be thoroughly cleaned and decontaminated before sterilization. Failure to remove all biological debris and residues can interfere with the effectiveness of the sterilization process. Typically, this is an enzymatic solution that the instruments must soak before being placed in peel packets or wrapped for sterilization.

2. Overloading the Sterilizer: Packing too many instruments into the sterilizer can prevent the sterilant (such as steam or ethylene oxide) from circulating correctly, leading to incomplete sterilization. Common sense tells us that the instruments must be loosely placed in the packets to ensure their sterile status. Using the smaller packets when the larger ones should be used is also a big no-no.

3. Incorrect Packaging: Using inappropriate packaging material or incorrect packaging techniques can affect the penetration of the sterilizing agent and the maintenance of sterility after the process.


Each type of sterilizer and instrument requires specific processing conditions (temperature, pressure, humidity, time). Not adhering to these specifications can result in inadequate sterilization. This was considered a threat to the patient's life and safety and cost the facility its accreditation. It took one observation of the surveyor, and everything worked; all lost immediately!

5. Lack of Proper Training and Education: Insufficient training for sterile processing personnel can lead to sterilization protocols and practice errors. Continuous education is necessary to stay updated with the latest standards and technologies. When assessing new employees or during annual reviews, the staff competencies need to be evaluated by someone who you know does the processing of the instruments correctly. Do not assume; it's hazardous!

6. Inadequate Inspection and Maintenance of Sterilization Equipment: Regular inspection and maintenance of sterilizers are essential to ensure they operate correctly. Failure to do so can lead to malfunctions and ineffective sterilization.

7. Improper Loading Techniques: Incorrect placement or orientation of instruments within the sterilizer can hinder the sterilizer's ability to reach and sterilize all surfaces of the instruments.

8. Ignoring Sterilization Indicators: Sterilization indicators, both external and internal, are used to verify the effectiveness of the sterilization process. Neglecting to use these indicators or misinterpreting their results can lead to using non-sterile instruments.

9. Failure to Adhere to Storage and Handling Guidelines: After sterilization, instruments must be stored and handled correctly to maintain their sterility until use. Mistakes in storage or handling can contaminate sterile instruments.

10. Not Documenting the Sterilization Process: Documentation of each sterilization cycle, including the items sterilized, the cycle used, and the cycle outcome, is crucial for tracking and validation purposes. Inadequate documentation can make tracing issues challenging or prove that sterilization standards have been met.

Ongoing training, adherence to protocols, and regular audits of sterilization practices are essential to minimize these errors. This ensures the safety and efficacy of surgical procedures and contributes to patients' overall well-being.

32 views1 comment

1 Comment

Rated 0 out of 5 stars.
No ratings yet

Add a rating
Mar 07
Rated 5 out of 5 stars.

Its so easy for us doctors to assume staff are properly trained when hiring from another facility. This blog post is a good reminder that we should never assume, and be due diligent with the competencies as you've explained. Thank you, Troy!

Dr. Agerwel

bottom of page