DATE

SPS SHIFT
PROCESSED
EFFECTED AREA
DESCRIPTION OF PROBLEM
RESOLUTION/COMMENTS
4/1/2014 1 OR-CARDIAC
VEIN HARVESTING TRAY HAD WRONG SCISSORS DUE TO SPS USING
THE WRONG COUNT SHEET
4/1/2014 2 OR-ORTHO
PAN OPENED AND WAS MISSING INDICATOR
PAN SENT BACK TO SPS FOR
REPROCESSING/PATIENT
DELAYED 1 HR 50 MINUTES
4/2/2014 2 OR-GI
COUNT SHEET STATES NO ROCHESTERS IN TRAY; 4 ROCHESTERS
WERE IN TRAY
4/3/2014 2 OR-CARDIAC
4 COUNTS ON SHEET WERE LEFT BLANK-INSTRUMENTS WERE PRESENT
ON TRAY
4/4/2014 1 OR-VASCULAR
MINOR PAN DID NOT HAVE CLIP ON OUTSIDE-COULD NOT USE PAN
RETURNED PAN TO SPS;
OBTAINED ANOTHER PAN
4/7/2014 2 OR-GENERAL
ARMY-NAVY RETRACTOR IN PAN WAS BROKEN
4/8/2014 2 OR-VASCULAR
KELLY WICK TRAY HAD CRACKED AND CHIPPED COATING TRAY TAKEN OUT OF SERVICE
4/8/2014 2 OR-CARDIAC WRONG COUNT SHEET USED X 3
OR OBTAINED CORRECT COUNT
SHEET
4/11/2014 2 OR-VASCULAR
SCANLON TUNNELER CASE (LABELED INCORRECTLY) HAD CRACKED
AND CHIPPED COATING
HAD TO TEAR DOWN AND RE-SET
UP
4/11/2014 1 OR-VASCULAR
TRAY LABELED MAJOR TRAY INSIDE WAS A MAJOR ORTHO TRAY HAD TO GET CORRECT TRAY
4/16/2014 2 OR-GU
NO STERILIZATION LOCKS ON CONTAINER
4/21/2014 0 OR-DAVINCI WHITE POWDERY SUBSTANCE ALL OVER CONTAINER
CONTAINER AND CONTENTS
REPROCESSED
4/22/2014 1 OR-VASCULAR
WHEN SETTING UP FOR A VASCULAR PROCEDURE INSTEAD OF HAVING
LARGE CARDIOVASCULAR PROCEDURE PACK, THE CASE CART HAD A
CYSTOSCOPY PACK ON IT.
DELAY IN SET UP-HAD TO HAVE
SPS SEND CORRECT PACK
4/22/2014 0 OR-CARDIAC
SIDE ARM ATTACHMENT MISSING FROM MITRAL VALVE EXTRA PAN
PATIENT HAD PROLONGED TIME
UNDER ANESTHESIA AND
SURGEON EXPERIENCED
DIFFICULTY IN PERMAING
PROCEDURE
CLOSE CALL/REPORTED ISSUES IN SPS-APRIL
4/23/2014 2
OR-GENERAL
INVENTORY
WHEN PUTTING AWAY STERILE PEEL PACK ITEMS 4 PACKAGES WERE
FOUND WHICH WERE NOT SEALED-ITEMS CHECK BY MULTIPLE
EMPLOYEES
SPS TECHS COUNSELED AND PEEL
PACK ITEMS HAD TO BE
REPROCESSED
4/29/2014 1 OR-CARDIAC
WHILE SETTING UP FOR CHEST CASE THE WIRE CUTTER WAS FOUND
TO BE BROKEN
LEGEND: 1-ITEM MISSING 2-MISCOUNT 3-DAMAGED 4-WRONG ITEM(S) 5-CANNOT GUARENTEE STERILITY
CODE*
4
5
2
2
5
3
5
2
5
4
5
5
4
4
CLOSE CALL/REPORTED ISSUES IN SPS-APRIL
5
3
WEEK DEFECTS
1 3
2 0
3 0
4 3
5 3
6 0
7 1
8 4
9 3
10 3
11 17
12 10
-20 0 20
NWEEK
DEF
-2
0
2
4
6
8
10
12
14
16
18
1 2 3 4 5 6 7 8 9 10 11 12
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WEEK NUMBER NOV-FEB
TRACKING ISSUES IN SPS