Breadcrumb

Healthcare Inspection – Alleged Sterile Processing Service Deficiencies, VA Puget Sound Health Care System, Seattle, Washington

Report Information

Issue Date
Report Number
13-01351-296
VISN
State
Washington
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to assess allegations regarding operations within the Sterile Processing Service (SPS) at VA Puget Sound Health Care System (the system) Seattle, WA. We substantiated that instruments were processed in a pan that was not approved for the sterilizer in use; however, we did not substantiate that this caused the instruments involved to be unsterile. We did not substantiate that leadership knowingly covered-up and failed to disclose processing problems associated with equipment. We did not substantiate that the system reused single-use devices; however, we did find that the system resterilized single-use devices that had not yet been used. We did not substantiate that standard operating procedures and staff competency folders are not accurate and current or that SPS had not provided sufficient staff training. However, we did find deficiencies in the manner in which the files were organized. We concluded that the system generally complied with clinical and administrative processes within SPS. We found areas needing improvement in the management of single-use devices and the maintenance and tracking of SPS staff competency files.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Sterile Processing Service has a process in place to identify single-use devices and mitigate the risk of single-use devices being resterilized.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that processes be strengthened to ensure that Sterile Processing Service staff competency records are well organized and that managers are able to readily determine the current competence of each person on each task.