Missing Instruments (PDF)

Elimina'ng Missing Instruments M issing instruments are surgeons schedule procedures, they failure if count sheets do not have the a common challenge count on the instrument trays being critically needed information, including...

Elimina'ng Missing Instruments M issing instruments are surgeons schedule procedures, they failure if count sheets do not have the a common challenge count on the instrument trays being critically needed information, including for Sterile Processing complete and ready for surgery. Missing the manufacturer, catalog numbers, departments (SPDs). instruments are a problem SP Instrument instrument descriptions, and quantity. This lesson will Specialists should strive to prevent Whether a tray menu is electronic or address the importance of proactively – before they have a chance hard copy, the count sheet must be minimizing the occurrence of to impact the OR. Many may wonder accurate to ensure that SP technicians missing instruments and developing what causes missing instruments, and can get the right instrument in the right and maintaining an organized the answer will likely vary depending tray. storage and reorder system. upon who is asked. Some SP Instrument Because there are hundreds of thousands Specialists might claim the OR is or surgical instruments, critical pieces of Objec&ve 1: Discuss the largely responsible. Those in the SPD the tray menu are manufacturer importance in maintaining typically blame the OR team for information and catalog numbers. Most accurate count sheets throwing away instruments with the SP technicians have “bread and butter” drapes on the back table. On the other instruments memorized like Mayo Most SPDs track tray errors. These hand, many OR team members might scissors and #3 knife handles, and typically involve incorrect envision a black hole of sorts in the SPD advanced SP technicians will have a instruments, packaging errors, where all the critical instruments are variety of instruments memorized from damaged instruments, etc. Most mysteriously collecting. Healthcare an assortment of service lines. For departmental leaders do not count administrators do not care what is example, they can explain the difference missing instruments as a tray error if causing the problem; they just want an between Debakey, Satinsky and Cooley the instrument is marked “missing” end to the never-ending expenses vascular clamps. Even the most on the tray menu and labeled on the associated with replacing missing experienced SP technician, however, outside of the tray; however, most surgical instruments. In reality, the root may struggle to know the differences surgeons and Surgical Services cause of missing instruments is between similar instruments on ear, eye leaders would argue that missing complex. Missing instruments are and other microsurgery instruments. instruments are the highest typically caused by instruments mixed Without the manufacturer’s catalog frequency tray error and are a direct between sets, prioritization systems that information on tray menus, new hires contributor to delays and frustration leave critical instruments behind, bad will struggle to learn the jargon and in the surgical suite. Missing data on critical tray count sheets, and no memorize the specialized instruments in instruments in surgical trays can halt replenishment system to replace their new SP roles – and even long-term surgical cases and cause Operating damaged instruments. For the purpose employees may struggle or avoid trays Room (OR) circulators and SPD of this lesson, let’s focus on what the with less familiar instruments. The result runners to stop their work to go SPD can control. for both groups is the wrong instruments search for the missing critical in trays and instruments marked instrument. It is not uncommon for “missing.” When the manufacture’s multiple SPD technicians to be Coun&ng on Count Sheets catalog information is accurate and pulled from their job assignments Surgical tray menus are the critical tool included on tray count sheets, and spend 15 minutes or longer ensuring the success or failure of SPDs. experienced and new SP technicians can searching for a critical instrument, Count sheets are the communication tool “paint by number” to assemble which creates waste, frustration and where the OR team ensures that the SPD specialized surgical instrument trays. backlogged work. Organizations team knows exactly which instrument When this happens, tray assembly speed spend hundreds of thousands of belongs in which tray. Bad data on tray and accuracy is improved, missing dollars annually replacing missing menus leads to the wrong instruments in instruments can be located, and instruments. This stems from the trays, no information to order replacement instruments can be ordered, surgical procedure itself being replacement instruments, and failure to if needed. One of the root causes to delayed or, even worse, canceled follow the manufacture’s instructions for missing and/or incorrect instruments is because the missing instrument is use (IFU) for instrument processing. poor descriptions for surgical critical to the procedure. When Instrument Specialists are set up for instruments on count sheets. the surgical instrument trays likely have or wear (e.g., osteotomes) should also be Considering the following: years’ worth of poor instrument included. substitutes or incorrect instruments. As trays are processed through the SPD, Objec&ve 3: Review the Six Sigma Forcep Allis wrong instruments will be removed, and technique of 5S for instrument Allis Clamp correct instruments will be placed in organiza&on. Allis Clamp Med trays. This may result in a short-term Allis Clamp 7in increase in missing instruments as Once the selection of instruments is Forcep Allis Tissue Straight 6 ¼” incorrect instruments are removed and completed, the back-up instrument area replacement instruments are should be organized in a way that makes All of these descriptions may be unavailable. it easy to locate instruments quickly. Six asking for the same instrument; Sigma has an organization technique however, only the last instrument known as 5S. This technique, which description (Forcep Allis Tissue includes the following, results in items Straight 6 ¼”) will result in SP Objec&ve 2: List steps to build an being organized in a way to make it technicians consistently putting the effec&ve replenishment system to intuitive to find and locate the critical correct instrument in the correct tray. replace missing and nonrepairable item when needed: For the other examples, SP surgical instruments. technicians may put a variety of lengths or thicknesses of Allis Surgical instruments undergo wear and Sort: The first step in a 5S project is to forceps in instrument trays. tear during surgical procedures. SPDs sort. Sort instruments that are needed Additionally, technicians may not be have preventative maintenance systems from instruments that are old inventory able to replace an instrument set up to repair and maintain the and will never be used. Many third-party because they do not have enough functionality of the instruments. Over instrument vendors and some information. Often, hospitals use time, the instruments become manufacturers will purchase old their own jargon on tray menus. For nonrepairable. When instruments are instrument or give trade-in credit toward example, a Rochester Eastman damaged beyond repair, the SPD must new purchases. Remove any broken retractor is listed as a Kelly retractor. have a replenishment plan. The damaged instruments and send them for There is no sizing information, and it replenishment plan should include a repair if they can still be used. For any is the incorrect name. The OR system for having instruments on hand nonrepairable instruments or dead cannot understand why those in the for high-use instruments and a separate inventory that is unsellable, consider SPD cannot get it right. SP system for purchasing replacement recycling. The important thing is to only technicians must get it right, and the specialty instrumentation. Departments keep instruments in the backup inventory way to get there is by having can build a back-up supply of that will be used. accurate tray menus with standard instruments, either through purchasing nomenclature for instrument names. high-use instruments or engaging in a Set in order: The next step in a 5S project The following is an example of a consignment system with their is to set in order. Organize instruments to simple instrument standard contracted instrument vendor. Some promote workflow and place high-use nomenclature that is effective: instrument repair companies will instruments in easy-to-reach locations; instrument type, inventor or include replacing high-use instruments low-use items should be located farther scientific name, description of as part of their repair service. The away. Instruments primarily used in the direction/curvature, length, and instruments in any of these systems low-temperature sterilization area should thickness (if applicable). This must be the right mix of instruments and be stored there. If the instruments are structure ensures technicians can organized in a way to ensure SP primarily used to replace nonrepairable quickly read tray menus to match technicians can find the instrument they instruments, perhaps they should be their instruments to the count sheet. need as quickly as possible. Instrument located near where trays are checked It also ensures they have the use should be analyzed to identify the back in from the onsite repair team. information to find their instrument most frequently used instruments in the Organize the space so it is easy and in other trays or from the back-up department. For departments with intuitive to use. wall, and it drastically reduces the surgical instrument tracking systems, the risk for technicians putting the information can be exported by the Shine: The third S in a 5S project is to incorrect instrument in a surgical system. It is important to evaluate the shine. The area should be cleaned, so it instrument tray. As instrument count frequency of use for each type of is neat and tidy. Dust the back-up wall sheets are cleaned and completed, instrument across all trays. The peg board or bins. Remove and replace the SP leader needs to ensure the department should focus on creating par any old or worn labeling. Remember, technicians understand that “close levels for back-up instruments matching instruments stored in the back-up area enough” substitutes are not highly used instruments. Instruments will be placed in trays for surgery; they acceptable. When an organization with a greater risk/tendency for damage should be stored in a clean, sanitary has had poor information for years, environment.  cannot be performed without the happens, instrument trays then arrive in critical instrument. If the instrument is the assembly area, Instrument Specialists Standardize: The fourth step in a 5S not available, the organization may attempt to assemble the trays and, project is to standardize. One of the need to borrow or get loaned unfortunately, the sets are missing most effective tools for instruments, or worst case, reschedule instruments that are still in other trays standardizing a backup wall is use surgeries. Note: This should be vetted from the original case cart in Kanban cards. Kanban is a visual as soon as possible to reduce any decontamination. The instruments are indicator that an action needs to patient care impact that could occur. marked as missing, and the trays are occur. Kanban cards for instrument After the instrument is confirmed lost back-up walls typically have an or nonrepairable and communicated to sterilized. The next morning, when the image of the instrument, the OR team, the SP team then needs to tray is used in surgery, it is missing manufacturer, catalog information, order the instrument. Ideally, the tray critical instruments. The instruments are and a reorder point or par level. The information can be included on the then found in the SPD and the OR team Kanban cards are placed on the pegs purchase order or documented to print cannot understand why the SPD “cannot and in the bins of the back-up wall. on the delivery receipt when the get it right.” This serves two purposes: first, SP instrument arrives. This will simplify Instrument Specialists should focus on technicians have labels with images the process for getting the instrument what they can control and avoid the for each instrument. This keeps the on the right tray as quickly as possible. blame game. The SPD can control the back-up wall organized, and when flow of instruments through new instruments come in, they can decontamination and assembly. Trays be quickly put in the right location. Objec&ve 4: Discuss the from the same case cart should be kept The second purpose leads to importance of flow through Sterile together through decontamination and sustainability. Processing decontamina&on and assembly. This will reduce search time in assembly areas to eliminate the instrument assembly area and reduce Sustain: The final S in a 5S project preventable missing instruments. the occurrence of preventable missing is to sustain. A system needs to be instruments. Tags validated for developed to ensure that the While the OR team can certainly decontamination processes can be used organization and replenishment of contribute to missing instruments, it is to keep these trays together through the the back-up wall stays in place. not always in the way most SP processes. Employee engagement and Kanban cards can be placed at the technicians believe. Many missing buy-in will ensure success for improving reorder points for the instrument the flow of instruments in an SPD. instruments mysteriously reappear the back-up wall. The cards have the following day in the SPD. Many SP critical information that the Conclusion professionals may have experienced the requisitioner will use to order While missing instruments will remain OR coming to the SPD and finding a replacement instruments. At least an issue in the SPD, the occurrence annually (if not more often), the critical instrument in a random bin. Most can be decreased. By focusing on the organization should reanalyze the SPDs experience this daily and in large processes that can be controlled by the instrument utilization data and “mega departments,” it can occur several SP technicians and developing an nonrepairable instrument trends to times a day. This type of missing organized and well-maintained system adjust the back-up wall instrument instrument root cause is typically the OR of instrument processing and missing mix, as appropriate. Having a well- team mixing surgical instruments in instrument replacement, many of the functioning back-up wall is critical multiple trays. When instruments are occurrences of missing instruments for high-replacement instruments mixed on the sterile field and not resorted can be reduced. that are at end of live or prior to SPD receipt, this increases the nonrepairable; however, facilities risk for missing instruments. In the SPD, can have over 20,000 types of there typically is a list of priority trays for instruments in their instrument the day; these trays are pushed through trays. Not all instruments can be decontamination as soon as they arrive managed through a back-up wall. For those specialty instruments that because they are needed for surgeries are high value, low utilization, or later in day. One-of-a-kind trays can be super specialized, the organization fast tracked through the decontamination will need an alternative system for area. If there is not a consistent flow managing missing and process, SP technicians can choose nonrepairable instruments. The which instruments to send through in specialized instrument should be which order. All these behaviors lead to communicated to the OR. Some the same issue: instrument trays from the instruments are so specialized that same case cart being sent through the the associated surgical procedures washers at different times. When this