The Joint Commission standards require that a hospital’s infection control and prevention policies include oversight of sterilization procedures used on critical patient care items such as instruments and devices used in the operating room. The Sterile Processing Department (SPD) performs the decontamination, sterilization, storage, and delivery of required instruments to hospital departments. The risks present when failure to follow TJC standards in the SPD are high, including the potential for patient contamination, loss of life, litigation, loss of accreditation and/or Centers for Medicare and Medicaid Services deemed status, and loss of reputation. Therefore, this session would include a discussion of:
• What the SPD is and the importance to healthcare facilities.
• Applicable regulations and leading practices.
o TJC
o CMS
o AAMI
o AORN
o CDC
o ASHRAE
• Where potential risks lie within SPD departments and the controls to mitigate them:
o Training and certifications
o Maintenance of equipment
o Maintenance of the SPD environment
o Sterilization of instruments
o Incident reporting
o Immediate use steam sterilization
o Tracers
• How to plan an audit over SPDs