Spend one day in a busy Sterile Processing department and you will be confronted with the critical impact errors can have on a surgical workflow. These surgical instrument reprocessing errors can lead to everything from minor inconveniences to life-threatening "never events." Forgotten indicators, incorrect light cord attachments, reversely assembled retractor handles, and bone-laden rongeurs -- the list of potential and actual errors can be incredibly long and understandably frustrating for surgeons, operating room personnel, and Sterile Processing team members.
As dangerous and disappointing as these errors can be, they can and should be teaching us something about our workflows, standard operating procedures, training, and tools. Errors are the check engine light on our department dashboard, signaling to us that something about the current process may not be all that it appears to be from the outside. Errors function much like the body's pain sensations when we get too close to fire, sending up a flare that says "Stop! What you are doing could end up badly for you!"
All this is straight-forward enough. Reprocessing errors, while dangerous, also give us invaluable feedback to the current state of our processes in SPD -- if we see them, document them, and respond to them. But wait, there's more...
What's the big idea? The Need for Networked Error Databases
Forgive me briefly if I use the tired and now nearly clichéd metaphor of the airline industry -- hopefully with a memorable twist. Imagine if each individual aircraft kept its flight error logs to itself. When a 737 had engine troubles, only that particular pilot and mechanic addressed it. When an Airbus A320 required an emergency landing in Nebraska, no one except the people on board ever knew anything about it. When jet liners across town crashed, no one ever connected the dots.
Let me just come out now and state the obvious -- THIS IS OUR REALITY in Sterile Processing. We keep our error data to ourselves. We track diffe