An infection control breach occurs when unsterilised instruments are released into circulation and used on patients without being successfully sterilised.
One of the most common ways that a breach occurs is when an autoclave does not complete a cycle successfully, or when it is unloaded without being switched on and the cycle processed.
This usually occurs when care is not taken to ensure that when pressing “start cycle” (or similar) that the unit actually begins its cycle. This can be a problem when the touchscreen on the unit is old and no longer as sensitive.
Another common situation is when the autoclave is loaded (either fully or partially) but the cycle is not started, and a second person comes along and unloads the items without checking the screen, parameters or chemical indicators. The items are then released into circulation, and if no one is mindful when setting up their rooms for a procedure and checking the bags/pouches when opening items then these contaminated instruments can be inadvertently used on patients.
If this occurs, there is a protocol that must be followed for containing the breach, recalling instruments and informing any potentially exposed patients of the breach.
INFECTION CONTROL BREACH MANAGEMENT PROTOCOL:
