A Setup Interrupted

In practice

Halfway through setting up for a knee replacement, Lee, the scrub person, is called out of the room urgently to help move a patient in the hallway. Lee is gowned and gloved and the back table is open. The circulating nurse is also called away. For several minutes, nobody watches the field. When Lee returns, the field looks untouched. Nothing appears out of place, and the room was empty the whole time, as far as anyone knows. Lee's first thought is that the field is probably fine. Lee's second thought is the rule: a sterile field that was not watched is considered contaminated, because no one can say what touched it. Lee tells the circulating nurse that the field was left unattended and asks what the facility's policy requires. The policy is clear: the field is broken down and set up again. Lee removes the gown and gloves, the opened items are taken down, and new sets and supplies are opened. Some items were expensive, and the delay is about twenty minutes. At the debrief, the team agrees that next time someone must stay with an open field, or the field is covered according to facility policy before both staff leave.