Action 3.17 states

When reusable equipment and devices are used, the health service organisation has:

  1. Processes for reprocessing that are consistent with relevant national and international standards, in conjunction with manufacturers’ guidelines
  2. A traceability process for critical and semi-critical equipment, instruments and devices that is capable of identifying
    • the patient
    • the procedure
    • the reusable equipment, instruments and devices that were used for the procedure
  3. Processes to plan and manage reprocessing requirements, and additional controls for novel and emerging infections

Intent

Where reusable equipment and devices are used, the health service organisation minimises infection risks to patients and the workforce by ensuring adequate identification of, and procedures for reprocessing, reusable medical equipment.

Reflective questions

  • Is there a process for identifying reusable equipment, instruments and devices that need to be reprocessed?
  • What processes does the organisation have in place to plan and manage reprocessing requirements for novel and emerging infections?
  • How does the organisation ensure that reprocessing of reusable medical devices follows relevant national standards and manufacturers’ instructions?
  • How does the organisation identify the patient, the procedure and the reusable equipment, instruments and devices that were used?
  • What mechanism does the organisation have in place to identify and communicate to patients at risk of acquiring an infection as a result of the reusable instruments and devices used?
  • How is the sterile stock and reprocessed equipment transported, stored and maintained?

Examples of evidence

  • Policies, procedures and/or protocols for processing reusable medical equipment, instruments and devices that are consistent with relevant national or international standards and manufacturer’s instructions for use
  • Policies, procedures and/or protocols for the use of reusable medical equipment, instruments and devices
  • Risk assessment and management plans for novel and emerging infections that addresses reprocessing requirements
  • Risk assessments where there are deviations in the requirements of relevant standards and the manufacturer’s instructions
  • A register of approved reusable medical devices
  • Access to or copies of manufacturer’s instructions for reusable medical devices
  • Records of sterilisation that verify instrument reprocessing is consistent with relevant national or international standards
  • Maintenance schedules for equipment used to reprocess equipment, reusable instruments and devices are monitored and reviewed
  • Training documents and registers of staff training and competency assessments
  • Audit of validation and compliance monitoring systems for sterilisers
  • Audits of sterile stock integrity and supply
  • Audit and report on workforce compliance with policies for processing reusable medical equipment, instruments and devices
  • Relevant documentation from committees and other meetings where reports on reprocessing processes and traceability systems are reviewed and discussed
  • Register or record of consumers who have had procedures using reusable instruments and devices
  • Observation of a traceability system that allows individual identification of clients and the reusable devices, equipment or instruments used during the care of each client
  • Audit of patient healthcare records or surgical lists to identify documentation of   the use of reusable medical instruments and devices
  • Report of clinical incidents related to reusable medical equipment, instruments and devices
  • Improvement/action plans informed by local audits of current practice, changes in state or territory requirements or national guidance or standards.

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