Skip to main content
Top
Published in: BMC Health Services Research 1/2019

Open Access 01-12-2019 | Research article

Errors in packaging surgical instruments based on a surgical instrument tracking system: an observational study

Authors: Xiaolian Zhu, Lan Yuan, Tianyi Li, Ping Cheng

Published in: BMC Health Services Research | Issue 1/2019

Login to get access

Abstract

Background

Surgical instrument processing is important for improving the safety of surgical care in hospitals. However, it has been rarely studied to date. Errors in surgical instrument processing may increase operative times and costs, and increase the risk of surgical infections and perioperative morbidity. We aimed to investigate the errors occurred in packaging surgical instruments.

Methods

Surgical instrument tracking system in a central sterile supply department (CSSD) was used to collect the packaging data during January–August 2016 in the First Affiliated Hospital of Soochow University, Suzhou City, China.

Results

Data on 33,839 surgical instrument packages were collected. A total of 398 (1.18%) errors occurred, including incomplete packages (n = 70), instrument missing (n = 77), instrument malfunction (n = 27), instrument in wrong specification (n = 175), wrong packaging tag (n = 8), box and cover mismatched (n = 14), wrong packing material (n = 15), indicator card missing (n = 6), and wrong count of instruments (n = 6). The highest error rates were observed among least experienced nurses (N1 level) and during the 16:00–20:00 time period (both p < 0.05). A relatively high error rate was detected in the Department of Orthopedics as well as in the Department of Gynecology and Obstetrics.

Conclusion

Wrong instrument specifications were the primary packing error identified in the current study. Further effort is needed to standardize the packing procedure for instruments under the same category and more effort is required to reduce the error rate during high risk times, or in the surgery department.
Literature
1.
go back to reference Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care. 2002;14(4):269–76.CrossRef Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care. 2002;14(4):269–76.CrossRef
2.
go back to reference Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126(1):66–75.CrossRef Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126(1):66–75.CrossRef
3.
go back to reference Blackmore CC, Bishop R, Luker S, Williams BL. Applying lean methods to improve quality and safety in surgical sterile instrument processing. Jt Comm J Qual Patient Saf. 2013;39(3):99–105.CrossRef Blackmore CC, Bishop R, Luker S, Williams BL. Applying lean methods to improve quality and safety in surgical sterile instrument processing. Jt Comm J Qual Patient Saf. 2013;39(3):99–105.CrossRef
4.
go back to reference Nicolay CR, Purkayastha S, Greenhalgh A, Benn J, Chaturvedi S, Phillips N, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg. 2012;99(3):324–35.CrossRef Nicolay CR, Purkayastha S, Greenhalgh A, Benn J, Chaturvedi S, Phillips N, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg. 2012;99(3):324–35.CrossRef
5.
go back to reference Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.CrossRef Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.CrossRef
6.
go back to reference Ryckman FC, Schoettker PJ, Hays KR, Connelly BL, Blacklidge RL, Bedinghaus CA, et al. Reducing surgical site infections at a pediatric academic medical center. Jt Comm J Qual Patient Saf. 2009;35(4):192–8.CrossRef Ryckman FC, Schoettker PJ, Hays KR, Connelly BL, Blacklidge RL, Bedinghaus CA, et al. Reducing surgical site infections at a pediatric academic medical center. Jt Comm J Qual Patient Saf. 2009;35(4):192–8.CrossRef
7.
go back to reference Chen TT, Chang YJ, Ku SL, Chung KP. Statistical process control as a tool for controlling operating room performance: retrospective analysis and benchmarking. J Eval Clin Pract. 2010;16(5):905–10.CrossRef Chen TT, Chang YJ, Ku SL, Chung KP. Statistical process control as a tool for controlling operating room performance: retrospective analysis and benchmarking. J Eval Clin Pract. 2010;16(5):905–10.CrossRef
8.
go back to reference Gagneux E, Lombrail P, Vichard P. Trauma emergency unit: long-term evaluation of a quality assurance programme. Qual Health Care. 1998;7(1):12–8.CrossRef Gagneux E, Lombrail P, Vichard P. Trauma emergency unit: long-term evaluation of a quality assurance programme. Qual Health Care. 1998;7(1):12–8.CrossRef
9.
go back to reference Li T. Implementation and effect of surgery-supply rooms integration management model. Modern Clinical Nursing. 2011;10(5):60–1. Li T. Implementation and effect of surgery-supply rooms integration management model. Modern Clinical Nursing. 2011;10(5):60–1.
10.
go back to reference Cao L. Application of information management system in the management of external surgery instrument. Med Inf. 2015;(39):26–7. Cao L. Application of information management system in the management of external surgery instrument. Med Inf. 2015;(39):26–7.
11.
go back to reference Duro M. Surgical instrument tracking system advancements and benefits. AORN J. 2014;100(1):7–8.CrossRef Duro M. Surgical instrument tracking system advancements and benefits. AORN J. 2014;100(1):7–8.CrossRef
12.
go back to reference Yao W, Chu CH, Li Z. The adoption and implementation of RFID technologies in healthcare: a literature review. J Med Syst. 2012;36(6):3507–25.CrossRef Yao W, Chu CH, Li Z. The adoption and implementation of RFID technologies in healthcare: a literature review. J Med Syst. 2012;36(6):3507–25.CrossRef
13.
go back to reference Mehrjerdi YZ. Radio frequency identification: the big role player in health care management. J Health Organ Manag. 2011;25(5):490–505.CrossRef Mehrjerdi YZ. Radio frequency identification: the big role player in health care management. J Health Organ Manag. 2011;25(5):490–505.CrossRef
14.
go back to reference Rosenbaum BP. Radio frequency identification (RFID) in health care: privacy and security concerns limiting adoption. J Med Syst. 2014;38(3):19.CrossRef Rosenbaum BP. Radio frequency identification (RFID) in health care: privacy and security concerns limiting adoption. J Med Syst. 2014;38(3):19.CrossRef
15.
go back to reference Ministry of Health of China. Comprehensive guide to steam sterilization and stearility assurance in health care facilities. 2016. Ministry of Health of China. Comprehensive guide to steam sterilization and stearility assurance in health care facilities. 2016.
16.
go back to reference Yumei L, Funi P, Chunxia L. Observation study on occupational hazard among nurses in supply room. Journal of Qiqihaer University of Medicine. 2014;35(11):1713–6. Yumei L, Funi P, Chunxia L. Observation study on occupational hazard among nurses in supply room. Journal of Qiqihaer University of Medicine. 2014;35(11):1713–6.
17.
go back to reference Meihua L, Huiyi T, Shuqin L, Xueyi H. The effect of detailed management in nursing service process. Chin J Nurs. 2006;41(9):826–7. Meihua L, Huiyi T, Shuqin L, Xueyi H. The effect of detailed management in nursing service process. Chin J Nurs. 2006;41(9):826–7.
18.
go back to reference Jingmiao M, Ping Y. A hypothesis in estabishing nursing safety levels in clincs. Chin J Nurs. 2010;45(4):348–9. Jingmiao M, Ping Y. A hypothesis in estabishing nursing safety levels in clincs. Chin J Nurs. 2010;45(4):348–9.
19.
go back to reference Chunmei W. Probe into application of flowsheet management to enhance quality control of nursing links. Chin Nurs Res. 2010;24(25):2326–7. Chunmei W. Probe into application of flowsheet management to enhance quality control of nursing links. Chin Nurs Res. 2010;24(25):2326–7.
20.
go back to reference Hao H, Xiaoli Z, Hui C. Value of classified training program in sterile supple cencer. J Nurses Training. 2012;27(15):1361–2. Hao H, Xiaoli Z, Hui C. Value of classified training program in sterile supple cencer. J Nurses Training. 2012;27(15):1361–2.
Metadata
Title
Errors in packaging surgical instruments based on a surgical instrument tracking system: an observational study
Authors
Xiaolian Zhu
Lan Yuan
Tianyi Li
Ping Cheng
Publication date
01-12-2019
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2019
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-019-4007-3

Other articles of this Issue 1/2019

BMC Health Services Research 1/2019 Go to the issue