July 1, 2013
Unprocessed tray incident prompts investigation, leads to process improvements
The circulating nurse was cleaning up after surgery in an ambulatory surgery center (ASC) when she noticed the internal chemical indicator (a Class 5 integrating indicator) had not reached its appropriate endpoint response, which is a pass. That meant an unprocessed instrument tray had been used on the patient. Her discovery set off an investigation to determine why this occurred.
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