CJD: Have you challenged your policy and procedure?
Yes, we have. The occurrence of prion or transmissible spongiform encephalopathy contamination, such as Creutzfeldt-Jakob disease (CJD), is a once in a lifetime event — if it occurs at your facility. However, if it does, it is likely to be one of those events that just could be your worse set of errors. Why, you might ask? The answer is simple: It is a remote chance (low volume=less experience) with high consequence (death).
When I worked with clients on developing competencies, I did not just include the standard important ones, such as a return demonstration on how to conduct a biological test on a prevac cycle. I made sure we included tasks or procedures that were unlikely, but had high ramifications if they failed; incorrect processing of instrumentation from a patient suspected of having CJD would be one example.
So, I challenge every sterile processing manager out there to re-evaluate their competency and quality assurance programs. Don’t reinvent the wheel when there are tools to help you, such as the FMEA (failure mode effects analysis) step-by-step tool, available for free at IHI.org. This tool helps to identify problems in your processes before they occur. This gives you an opportunity to correct steps and mitigate the risks identified. All for the purpose of patient safety (and not having having to conduct a “root cause analysis” post error).
Just a thought.