A Recall at Seven in the Morning

In practice

At seven in the morning, the processing department calls the operating rooms: the biological indicator from a steam load processed overnight has grown. The mechanical record for that cycle shows a temperature dip, so the sterilizer is taken out of service and the load is treated as nonsterile. Every package from the load carries the same load label, so the department lists them: four instrument sets, two of which have already been delivered to operating rooms for the first cases. In room three, Lee, the scrub person, is halfway through setting up, and one of the recalled sets is already open on the back table. When the circulating nurse reads the load number aloud, Lee stops at once. Nothing from that set has touched anything else, but the set, and anything it touched, is removed from the field. Lee breaks down the setup and starts again with a set from a different load, while the circulating nurse tells the surgeon about the delay and the reason. In room five, the recalled set is still wrapped and goes back unopened. No recalled item was used on a patient. The sterilizer is repaired and then verified with three consecutive empty cycles before it returns to use.