Question

A CST is working with a neurosurgeon on a left frontal craniotomy to remove a meningioma. He has just made the scalp incision when a unit charge nurse quickly enters the OR saying, “CSP just called, and there was a malfunction of the steam sterilizer last night. The sterilizer chart doesn’t confirm that these instruments went through a complete cycle even though the biological indicators have a negative reading.”

What steps should the OR team take at this point?

What is the concern if the biological indicators have a negative reading?

Discuss the chain of errors that took place that allowed the instruments to be transported to the OR, opened, and used.

Answer 1

• Any breach in sterility is of great concern and the entire set of equipments should be discarded as well as the OR must be changed for the present operation. General measures like re-sanitization of OR team must be done.
• This indicates that no detectable clinically significant amount of bacterial growth was recorded using the biological indicators. This does not necessarily rule out risk of contamination though.
• There can be many steps which have been overlooked here. Right from manual error to technical error or even operator error. The machine might not have been functioning properly, the operator did not cross check or see if the cycle has been completed and let it through, the healthcare staff assisting the surgeons might have overlooked this charting.