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Sterile Processing Case Studies Project

Sterile Processing Case Studies Project

Case Study 1


Effective decontamination of surgical equipment is one of the most critical steps that healthcare facilities can use to stop cross-contamination and the spread of health-acquired infections (HAIs) or nosocomial infections – which have been associated with increased costs of care, reduced patient safety, and other negative patient outcomes. More than often, persons involved in the decontamination process must strictly follow a specified set of instructions provided by the manufacturer as the equipment is delivered to the facility (Seavey, 2013). This case study evaluates decontamination problems at Baptist Medical Center. Neurosurgeon Sarmiento’s private scrub tech has found that contaminated neurological instruments have succeeded in getting into the operating room. Upon consulting the surgical services patient care manager, the scrub tech discovers the incident has been reoccurring for several months. This paper identifies the issue and potential causes, the extra precautions the sterilizing team must take when dealing with re-use instruments, how the sterilizing processing team can resolve the issue, and the step-by-step process of decontaminating surgical tools.

The Issues and Potential Causes

The issue of concern is that contaminated, unsterilized, or dirty neurological surgical instruments (such as curettes, dissectors, elevators, forceps, hooks, and rongeurs) have found their way into the operating or surgery room. The private scrub technician – whose role is to supply sterile equipment to the surgeon and maintain the operating room’s high sterility and cleanliness standards – has made the discovery and consulted the surgical service patient care manager. The most disturbing finding is that the issue has been reoccurring for the last few months without anyone noticing. This puts patients at risk of contracting health-acquired infections (HAIs), also known as hospital-acquired infections or nosocomial infections.

Several factors can be attributed to these errors. According to the Infection Control Today (2012) report, the causes of dirty surgical instruments in the OR can be classified into two: processes and people. Typically, the ‘processes’ factor relates to the handling and sterilizing procedures, while the ‘people’ factor involves the healthcare personnel involved in handling the surgical instruments, including sterilizing them and handing them to the operating room.

Firstly, mistakes during processing, sterilization, preparation, and presentation of surgical tools after exposure to neurological tissues can explain why some pathogens or dirt were found in the instruments. This can be attributed to the complexity of the design of surgical tools in modern times, making it extremely difficult to efficiently sterilize all parts of surgical tools (Seavey, 2013). Many difficult-to-reach parts make it challenging to completely sterilize surgical equipment, even when all cleaning instructions have been strictly followed. Furthermore, cleaning instructions issued by manufacturers might have been hard to read, not easily obtained, and inconsistent. Some instruments might also be complex, meaning they cannot be dismantled for inspection and sterilization. It is possible the facility lacks the right sterilization equipment to clean and sanitize all types of surgical tools. It is also likely that the healthcare facility failed to consult with the surgical services patient care manager while purchasing the equipment to find out if the care facility can meet all the instructions-for-use (IFUs).

Secondly, the errors might have stemmed from the incompetence of the sterilization personnel. The scrub technician and his team might have been unfamiliar with the procedures required to sterilize all or some of the equipment, leaving certain pathogens suspended (Infection Control Today, 2012). Besides, it is likely that the scrub technician failed to follow all the safety protocols when packaging, transporting, and storing the equipment into the operating room, such as wearing clean gloves, a face mask, and so on. Finally, the pathogens or dirt might have come from the operating room itself, meaning that the scrub tech failed to sanitize it up to the standard required.

Extra Precautions for Handling Surgical Instruments Exposed to Neurological Tissues

The sterile processing technician must observe three special precautions when sterilizing surgical equipment that has been previously exposed to neurological tissues. These three include cleaning, disinfection, and sterilization, in that order. Instrument cleaning is the first process and requires the use of clean or distilled water. This removes any logs or solid material from the surface of the surgical tissues, including dead tissue. The second step is disinfection and can entail the use of alcohol and other liquid chemicals. This step is essential in killing certain bacteria, particularly non-spore-forming. The final step is sterilization – which can be used to kill a plethora of disease-causing pathogens (viruses, parasites, and the remaining bacteria). A few common examples of sterilization techniques include ethylene oxide (gas) sterilization, steam (autoclave) sterilization, and dry glass (glass bead) sterilization.

How the Sterile Processing Department Can Address the Issue

The only way of resolving the issue permanently is to address the problem’s root cause: solve the ‘process’ and ‘people’ concerns. For processes, the sterile processing department should teach the scrub technician and the sterilization team about standard sterilization procedures, protocols, and processes. For example, they must train them on the three steps of sterilizing equipment exposed to neurological tissues, including cleaning, disinfection, and sterilization. Besides, the sterile processing department must consider replacing complex equipment that the facility has no capacity to effectively decontaminate (Seavey, 2013). If not, it can place an order requesting the facility to purchase these missing sterilization tools. Most importantly, the department should train the scrub technician about standard procedures for packaging, storing, and transporting the instruments to the operating room. The training should also entail cleaning and disinfection of the operating room itself, which, most times, is as well a considerable source of dirt and disease-causing microorganisms. Besides implementing all these recommendations, the facility must essentially take the responsibility of regularly tracking and monitoring the sterilization process to ensure that the previous mistakes are not repeated.

The Decontamination Process

Decontamination of surgical equipment is necessary to ensure the chain of pathogen transmission is broken. The following are the detailed steps involved in the decontamination process, as highlighted by the Association of Surgical Technologies (2009). The first step is cleaning surgical tools immediately after the surgery to avoid drying tissues debris, blood, and other dirt within the lumens and on the surface. Secondly, cleaning should proceed after the first cleansing step, including during disassembly and sorting, as well as packing into containers and shipping to the decontamination area or room. Clean the tools using detergents and cleaning materials. The detergent should clean effectively the instruments and not destroy the cleaning machinery. The cleaner must read all cleaning instructions provider by the manufacturer. Once the instruments have been effectively and completely cleaned, the right sterilization technique should be selected. Loaner instruments must also be sterilized upon receipt. The following sterilization techniques can be used, including ethylene oxide (gas) sterilization, steam (autoclave) sterilization, and dry glass (glass bead) sterilization.


It is evident from the case that contaminated or dirty surgical equipment made its way to the surgery room – which poses a health risk to patients. The decontamination process and people (staff tasked with handling the surgical equipment) are the two likely sources of the dirt discovered by the scrub tech in the OR. Thus, addressing these two loopholes can help the sterile process department to resolve the issue. The three decontamination steps include cleaning, disinfection, and sterilization. However, certain precautions must be taken to ensure the sterilized equipment reaches the OR germ-free or untainted. They must wear appropriate personal protective equipment (masks, gloves, gowns, and so on) to avoid contaminating the sterilized equipment again. Before their assembly and packaging, however, all equipment must be checked for damage, breakage, and unwashed debris. After decontaminating the instruments, the sterilization team should make an effort to assemble, package, and transport the tools aseptically.


Association of Surgical Technologies. (2009). Standards of practice for the decontamination of surgical instruments.

Infection Control Today. (2012, May 21). Dissecting the dirty instrument’s issue in healthcare facilities.

Seavey, R. (2013). High-level disinfection, sterilization, and antisepsis: Current issues in reprocessing medical and surgical instruments. American Journal of Infection Control, 41, 111-117.

Case Study 2


The CDC approximates that nosocomial infections or health-acquired infections (HAIs) are responsible for nearly 1.7 diseases in the U.S. each year and a subsequent 99,000 mortalities (Haque et al., 2018). Dirty or uncontaminated surgical tools (after contacting patient tissues) are the leading cause of nosocomial infections. For that reason, in recent years, leading health organizations like the World Health Organization have proposed a range of comprehensive measures to lower cross-contamination during surgery, particularly through dirty surgical instruments like forceps. Sterilization is one of these recommended procedures, and there are many sterilization techniques (Seavy, 2016). Like other procedures, the key to effective sterilization is ensuring that all instructions from the manufacturer are followed piecemeal. Sterilization technicians must ensure that all sterilization equipment is working perfectly and all the steps stipulated by the manufacturer are observed. This case study aims to evaluate the effects of a defective steam sterilization process. Kristine, a technician working in the sterile processing department, has just realized wet packs are being produced in 2 out of each of 4 loads sterilized throughout the day. She has consulted her senior on better ways of troubleshooting the problem of wet loads since the issue has impacted the unit’s quality control and efficiency.

This paper seeks to expand the understanding of the steam sterilization process by defining what wet packs and wet loads are, as well as explain the causes of wetness; and recommend solutions that Kristine can implement to address the moistening of instruments. How the issue can damage both the sterile processing department and operating will also be discussed, as well as ways Kristine can handle the wet packages to guarantee quality control.

Wet Packs and Wet Loads

The term’ wet pack’ refers to the existence of moisture on the outside or inside of a sterilized clinical/medical instrument. The term wet load is used when the wet packs are two and above. Wet packs can be a major aseptic issue because the suspended moisture can provide a potential medium or pathway for pathogen (bacteria, parasites, and viruses) transmission from the external surroundings to the wrapping material and subsequently contaminating the sterilized instruments. The issue of wet packs, particularly after sterilization, is widespread and is common in situations autoclaves are used – what is known as steam sterilization (Basu, 2018).

The Reasons the Loads Might be Wet

Wet packs and wet loads are frequent in steam sterilization. The occurrence of these products has been associated with a range of factors. The first one is using poor-quality packaging material. Typically, the primary reason the packaging of surgical instruments is done is to create a sterile barrier and maintain a germ-free environment up to the point the instrument is used. A good packaging material bars the bacteria and other germs from entering but allows air and steam inside. However, some nations are still applying reusable linen to wrap instruments during steam sterilization (Basu, 2018). The disadvantage of using this material to wrap sterilized clinical instruments is that the cotton thread can retain moisture during autoclaving. This steam can later condense and settle on either side of the wrapping material.

Another cause of moisture in packs is the poor condition of the sterilizing container. When using rigid container systems (for example, in autoclaves), moisture might condense in the post-vacuum stage, whereby the optimum pressure is dropped suddenly to atmospheric pressure (Seavy, 2016). Removing the moisture, even during the drying phase, is nearly impossible, meaning that some water will escape to the final packaged containers. Besides the poor condition of the container, faulty packaging methods can also result in the accumulation of moisture in the packs. For example, placing cotton rolls and gauze inside a surgical set is inappropriate because these materials can retain extra water vapor during drying. Packing linen items can also result in excess dense impermeable load in the surgical set. For this, a criss-cross method must be used to permit aeration.

Wet packs are also associated with improper loading methods. Inadequate space between instruments can affect aeration and subsequently result in sweating. Sterilizer malfunctions and poor steam quality (saturated steam and the presence of non-condensable gases like nitrogen and oxygen) can also yield wet packs. Besides, wet packs and wet loads have been linked to design-related issues. For instance, the huge temperature variation between the sterile store (20 ºC) and the autoclave (80 ºC) can result in quick condensation inside the surgical tool kit during storage (Basu, 2018).


Resolving issues with wet packs and wet loads requires sealing all loopholes that might permit moisture to get inside the packaging material in the first place. This includes carrying out regular or routine calibration and maintenance of autoclaves, avoiding equipment overloading, allowing sufficient drying time based on the written or manufacturer’s instructions, and allocating enough post-sterilization time, which gives enough room for the instruments inside the autoclave to adapt to room temperatures (Seavy, 2016). This will eliminate the possibility of dry air condensing. The next remedy is to avoid using protectors to guard the instruments’ tips. These protectors can hold extra humidity or dampness. Besides, technicians should avoid wrapping materials of poor quality (such as cotton) and avoid locking instruments “by all catches,” giving sufficient room for effective drying and steam penetration. Finally, the technicians should periodically monitor the drain valves and gaskets of autoclaves (rigid ones), ensure the size of the packaging material is large enough to accommodate the sterilized instruments, and install room heaters or de-humidifiers in storage facilities to avoid moisture accumulation (Basu, 2018).

Effects of Wet Packs and Wet Loads on the Sterile Processing Department and the Operating Room

Wet packs and wet loads pose a huge risk to both the Sterile Processing Department and the operating room. In the operating room, wet packs and wet loads can harbor or provide a medium for the entry of disease-causing microorganisms into the packaging material and, in the process, contaminate the sterilized instruments. This is a huge challenge because it means that using these contaminated items, especially for invasive procedures, can expose patients to a range of serious infections (Seavy, 2016). Therefore, web packs and wet loads can significantly compromise the safety of the operating rooms and, consequently, the health and well-being of patients. For the sterile processing department, the presence of wet packs and wet loads implies unprofessionalism and work neglect or laxity. In the U.S. and most jurisdictions across the world, the department is culpable of medical malpractice and can be sued in a court of law (Jasper, 2001).


A wet pack is a packaged clinical instrument with moisture logged on the sides of the packaging material or inside/outside the items. Wet loads are several wet packs clamped and generated within a specific timeframe. The occurrence of these products has been associated with a range of factors, including poor inventory management system, poor sterilizer condition, erratic design or planning of the CSSD (central sterile supply department), and poor steam quality. The others include poor load configuration and poor wrapping substance or material quality. Addressing the problem of wet packs and wet loads requires closing all channels that might permit water to accumulate in the packaging material. Wet packs and loads are a huge problem for the operating room because they can harbor bacteria, contaminating the instruments. This can predispose patients to deadly nosocomial infections. For the sterile operating department, wet packs in operating rooms are evidence of negligence and malpractice.


Basu, D. (2017). Reasons behind wet pack after steam sterilization and its consequence: An overview from Central Sterile Supply Department of a cancer center in Eastern India. Journal of Infection and Public Health,10(2), 235-239.

Haque, M., et al. (2018). Healthcare-associated infections – An overview. Infection and Drug Resistance, 11, 2321-2333. doi: 10.2147/IDR.S177247

Jasper, M. C. (2001). The law of medical malpractice. Oceana Publications.

Seavy, R. (2016). Troubleshooting failed sterilization loads: Process failures and wet packs/loads. American Journal of Infection Control, 44(5), 29-34. doi: 10.1016/j.ajic.2016.03.001.


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Sterile Processing Case Studies Project

OBJECTIVE: The purpose of the case study is to allow the student to analyze information retained over the duration of the sterile processing program and apply that knowledge obtained to provide specific solutions to common issues that may occur within the sterile processing department.


Choose two of the four topics as listed below: Decontamination Principles, Sterilization Methods, Preparation of Medical Equipment and Supplies, and Inventory Control and Distribution Systems. Once the two case studies are chosen, answer the questions using your own vocabulary and address the conflicts or issues with solutions specific to your topics of choice. To fulfill the requirements of this case studies project, you must employ research techniques. You can utilize your text or other credible sources from the internet to build a thorough paper that contains at least six main ideas with supporting details regarding the topic chosen and a minimum of three credible references. The paper must be written in APA format with an extensive introduction, body, and concluding statement per case study. Minimum of four pages, double-spaced excluding title and reference pages per case study. Please refer to the rubric regarding specific grading criteria.

Now that you understand the basic goals of this project, let’s get started.


  1. Decontamination Principles: Dr. Sarmiento is a well-known neurosurgeon at Baptist Medical Center. He is known for working on complex cases that involve the spine and other neurological tissues. This past week, his private scrub tech has discovered that dirty neurological instruments have made it into the OR. The technician consults with the patient care manager of surgical services because the incident has been reoccurring over the past few months. With this knowledge, respond to the following questions:
    • What issue(s) have occurred, and what may be the cause of these errors?
    • What other special precautions may the sterile processing tech need to take with instruments exposed to neurological tissues?
    • What might the sterile processing department have to do to resolve this issue?
    • Thoroughly explain the decontamination process. What extra efforts should be made to ensure that clean instruments are delivered to the surgical suite?

      Sterile Processing Case Studies Project

      Sterile Processing Case Studies Project

  1. Sterilization Methods: Kristine, a technician in the sterile processing department, has noticed that after the sterilization of surgical equipment and supplies that at least two out of every four loads sterilized for the day have been moist. She has consulted with her supervisor on effective ways in which she could troubleshoot the concerns with wet loads, because it has now affected the department’s work efficiency and quality control.
    • Define a wet pack.
    • Define a wet load.
    • Why might the loads be wet?
    • What solutions can Kristine apply to ensure that the processed instrument sets aren’t moist?
    • Discuss how this issue can affect both the operating room and the sterile processing department. How should Kristine handle the wet packages to ensure quality control?

Please review the following rubric to see how you will be graded for this final project. Ensure that all of these areas are covered to ensure the best achievable score.

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