A Tray That Came Back Dirty

In practice

Avery, the scrub person, opens a sterile instrument set for a hand surgery. The package is intact, the chemical indicator has changed as expected, and the expiration date is fine. While arranging the instruments, Avery notices dried brown material in the jaws of a small forceps. Avery does not wipe it off or set it aside. Avery tells the circulating nurse that the set has a soiled instrument. Because the set's contents have been in contact with the soiled item, the circulating nurse and Avery treat the whole set as unusable, and a replacement set is opened. The patient is not yet in the room, so the case is not delayed, and nothing from the soiled set has touched the patient. The soiled set goes back to the decontamination area, and the circulating nurse reports the problem to central processing, with the set's identification and load information. The processing team reviews the case: the forceps' joint had not been opened during washing, so soil remained inside. They recheck other sets washed with it, review how instruments were loaded, and remind staff to open every hinge before washing and to inspect under good light before assembly.