The Principles of Medical Device Decontamination

Inadequate chemical (e.g. hydrogen peroxide vapour) sterilisation These processes are likely to be less resilient than steam sterilisation, although there is far less experience with these comparatively new technologies. The severity of any defects in these processes should be explored with the steriliser manufacturer.

Post – process recontamination

Decontamination processes should follow a defined physical pathway through each step. An item that has been through any step should not make contact with a surface that has been in contact with other items which have not yet been through that step. If, for example, dental hand-pieces are taken from a steriliser and placed on a surface, or handled with gloves or forceps, that have made contact with instruments which have not been decontaminated, it will negate that decontamination. This is an example of a major failure.

Examples of options if a decontamination failure has been identified or is suspected

Actions should be identified by the investigating team; such actions may change as knowledge of the incident increases as an investigation progresses. If it is considered that the failure does not put the patients involved at any risk and to inform them would cause distress out of proportion with reality, then not informing patients is a realistic option. This decision should be agreed with the Executive Team so that the risk is owned by senior management. The incident should nevertheless be thoroughly investigated, and measures taken to ensure it does not occur again. If the failure may have exposed patients to microorganisms, including BBV or multi drug resistant bacteria, this is likely to become apparent long after the incident and specific prophylactic measures may be of limited benefit. The main options here are of informing relevant clinicians (e.g. consultant and/or GP) of the incident to increase their awareness, as well as the possibility of informing the patient if there are signs they should be made aware of, that indicate they should seek urgent help. In more serious cases, national health organisations (see below) can also be involved in the analysis and subsequent actions.

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