The sterile processing department (SPD) plays a critical role in both OR efficiency and safety. However, it often gets less attention because it isn’t seen as a revenue generator, and the risks of serious incidents are chronically underestimated. Hospitals constantly misjudge the number of SPD errors occurring every year because, oftentimes, errors are not properly tracked; what isn’t tracked can’t be evaluated or addressed. Satisfaction among staff decreases, and the risk of a broken or contaminated instrument reaching a patient goes up; the consequences are paid in hundreds of thousands or even millions of dollars.

In our latest podcast episode, we talked to Gregg Agoston, our Vice President for Service Lines Sales, and Marcy Konja, leads and manages our sterile processing business. Gregg and Marcy each have 30 years of experience primarily in sterile processing, and we asked them how the SPD could be improved in a way that prevents errors, increases satisfaction, and reduces risk.

Implementing an Accurate Error Tracking System

“One of the biggest challenges hospitals face is getting accurate data on SPD-related issues,” says Gregg. “Marcy and I often step into hospitals where the first hurdle is simply gathering data. Without a clear, data-driven approach, most facilities resort to broad solutions like additional education and training. While education is important, it’s ineffective if we don’t pinpoint where the problems originate.”

To tackle these issues, Gregg and Marcy developed a simple, streamlined system for the OR to report SPD errors.  Using SpecialtyCare’s process, in less than three minutes, OR staff can report the critical information SPD needs to find the root cause of the problem. Once implemented, hospitals see a dramatic increase in reported errors, often three to ten times more than before. This increase doesn’t mean the SPD is making more mistakes; it means errors are finally being seen on the level at which they’re occurring.

“Most errors are caught before they impact the patient, thanks to vigilant OR staff,” Gregg says. “However, a small percentage do slip through, leading to incidents with dirty, non-sterile, or broken instruments being used on patients. Our goal is to track and categorize these errors so we can tackle the root causes.”

Categorizing SPD Errors

According to Gregg and Marcy, SPD errors fall into 15 broad categories that encompass nearly all SPD-related errors in hospitals:

• Bioburden or foreign material in trays
• Wet packs
• Missing or incorrect filters, indicators, or locks
• Holes in wraps
• Broken or missing instruments
• Improperly assembled or disassembled instruments

After errors are categorized, real-time data from the OR can be recorded in a structured way. That’s when trends can be analyzed. For example:

• What technicians are involved?
• What shifts show higher error rates?
• Which supervisors oversee those shifts?
• Are errors linked to specific instrument sets, hospital-owned trays, or loaners?
• Which surgeons are impacted most frequently?

“This data-driven approach allows SPD managers to proactively address problems at their root by correcting staffing, staff proficiency, equipment/ supplies and/or efficiency to solve the issue,” says Gregg.

SPD Experience Matters

Marcy explains that error tracking has evolved since she started analyzing SPD operations in the early part of her career.

“When I first started in the 80s, my spreadsheet just listed the error type, who made the mistake, and what was done about it,” says Marcy. “Now, our system has evolved significantly. Greg took my original spreadsheet and put it on steroids, allowing us to drill down into every aspect of an issue.”

Today, Marcy and Greg are able to understand what’s causing certain errors. “If multiple technicians are making the same mistake, we analyze the process itself,” says Marcy. “If a particular shift has more errors, we evaluate workflow and staffing. If a certain OR keeps reporting issues, we check for communication breakdowns.”

The Cultural Impact of SPD Errors

SPD errors are typically caught by OR staff, but when errors are not tracked, reported, and addressed, they continue to occur. This can cause a deterioration of trust and morale among staff, leading to communication and conflict issues. Meanwhile, the root causes of the errors are not being addressed, and patients are still at risk.

“OR staff stops reporting errors when they feel nothing is being done to fix them,” says Marcy. “They think, ‘We’ve reported this issue over and over, and it’s never been addressed.’ This creates a communication breakdown between the OR and SPD, fueling frustration and finger-pointing.”

Gregg and Marcy work to restore trust by ensuring that the OR consistently reports issues, the SPD corrects those issues, and the SPD communicates back to the OR about the resolution.

“We don’t call out individual mistakes in a punitive way, but we ensure the OR knows we’re taking action,” says Marcy. “When the OR sees real improvements, they’re more likely to continue reporting errors.”

Gregg reiterates that the OR plays a critical role in the SPD’s operations. “The SPD depends on OR staff to properly handle instruments at the point of use,” he says. That’s why his and Marcy’s tracking system also evaluates:

• How well the OR follows point-of-use cleaning guidelines
• How organized the decontamination area is
• Whether SPD is receiving instruments in proper condition

With any manufacturing process the quality of the final product is determined in large part by the quality of the raw materials used.  The OR supplies the raw materials to the SPD to “build” the products (instruments and sets).  If the OR does not do a good job in supplying “high quality” (properly prepared) raw materials, it will negatively affect the final product. The #1 error we see is bioburden/ foreign material on instruments or in the tray.  The OR can have a direct impact on these events if they do not properly prepare the instruments after use.  “By looking at both sides of the equation, we can identify systemic issues in the supply chain, not just SPD-specific errors,” says Gregg.

Get Support to Improve Your SPD

Improving SPD’s production and quality has a direct positive impact on your OR performance, surgeon and staff satisfaction and ultimately patient care.  SpecialtyCare can provide SPD consultations, audits, and error tracking implementation; we can even place talented technicians or an SPD manager in your department to help improve operations, provide training, and reduce the instrument load. Don’t let your SPD jeopardize patient safety, bring down morale, or cause costly delays in the OR — give it the attention it deserves, and start seeing real results. Contact us today to find out how we can help!