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CIS Self-Study Lesson Plan

Sponsored by:
Lesson No. CIS 233 (Instrument Continuing Education - ICE) by Peggy Pittenger, RN, CRCST
Implementation Consultant/Customer Support
Unibased Systems Architecture, Inc.
Checklists for Central Sterile
Supply Departments
LEARNING OBJECTIVES
1. Explain the important role that check
lists can play in improving the effective-
ness of Central Sterile Supply Depart-
ment personnel.
2. Review procedures to maximize the
usefulness of one Central Sterile Supply
Department checklist: preference cards.
3. Describe useful tactics to plan and
develop CSSD checklists.
Instrument Continuing Education (ICE) lessons
provide members with ongoing education in
the complex and ever-changing area of surgical
instrument care and handling. These lessons are
designed for CIS technicians, but can be of value
to any CRCST technician who works with surgical
instrumentation.

Earn Continuing Education Credits:
Online: You can use these lessons as an in-service
with your staff, or visit www.iahcsmm.org for online
grading at a nominal fee.
By mail: For written grading of individual lessons,
send completed 15-question quiz and $15
to: PEC Business Ofce, Purdue University, Stew-
art Center Room 110, 128 Memorial Mall, West
Lafayette, IN 47907-2034.
Scoring: Each 15 question online quiz with a
passing score of 70% or higher is worth two points
(2 contact hours) toward your CIS re-certication
(6 points) or CRCST re-certication (12 points).
IAHCSMM provides online grading service for
any of the Lesson Plan varieties. Purdue University
provides grading services solely for CRCST and
CIS lessons.
More information: Direct any questions about
online grading to IAHCSMM at 312.440.0078.
Questions about written grading are answered by
Purdue University at 800.830.0269.
M
ODERN MEDICINE HAS BECOME AN EXTRAORDINARILY
complex environment. As a result, patients may experience medical
errors, which result in complications and even death. This is not because
the many people involved in their care lack knowledge about the right
thing to do. Rather, the complexity of the technologies used to diagnose and treat med-
ical problems has become increasing difcult to manage.

Consider the numbers: Currently, the World Health Organization (WHO) identi-
es over 13,000 diseases, syndromes or injuries. The combination of these maladies
raises the number of possibilities exponentially and makes patient care incredibly
challenging. Treatment options for those conditions include over 6,000 pharmaceutical
products and over 4,000 medical or surgical procedures. Considering the technology
and number of healthcare specialists involved, delivering treatment on time and safely
during a patient stay becomes a daunting task.
In response to the rapidly growing body of knowledge and technology involved with
patient care, WHO has turned to another industry the airlines to research methods
for improving patient care and reduce complications related to healthcare. The airline
industry is comparable to the healthcare industry on many levels.
Checklists in aviation date back to 1935. An investigation into the crash of a Boeing
299 that year revealed pilot error. The bottom line was that the plane had become too
complex for pilots to y. A new locking mechanism remained in the on position but,
with so many other new technical features, the pilot forgot to check it before the ight.
After this disaster, pilots collaborated to develop a simple solution: use a checklist to
assure critical steps are completed. Ultimately, this same airplane, later called the B-17
or ying fortress, ew nearly 2 million miles without further incident.
WHY CHECKLISTS?
Like the airplane pilot who knew the
steps required to prepare the plane for
ight, healthcare providers know the re-
quired steps to plan and conduct medical
procedures. However, also like the pilot, it
is possible for them to miss a step because
of the many complexities and distractions
in todays healthcare environment. When
this occurs, the results can be the medical
equivalent of a plane crash.
Another challenge in modern medi-
cine relates to the ongoing time pressures
experienced by busy healthcare providers.
This may result in knowingly overlooking
routine but very critical steps required for
a successful patient outcome. Carefully
developed checklists become the lifeline
CIS Self-Study Lesson Plan
for clinicians, just as they are with pilots,
to jog ones memory and ensure the com-
pletion of all vital tasks.
Many facilities have adopted the WHO
checklist in the Operating Room (OR)
to conrm that all critical steps are
carried out during perioperative care
(see Figure 1). A task as simple as
verifying the patients identity and
procedure, as well and body location
for the procedure, ensures that the right
patient receives the planned operation
on the correct side of his or her body.
Additional checkpoints conrm that
required instruments and equipment
are present and properly prepared.
CSSD CHECKLISTS
Checklists are a normal part of the rou-
tine in Central Sterile Supply Department
(CSSD). For example, the Instrument
Tray List or the Preference Card used to
build case carts for OR procedures are
basically checklists. CSSD personnel have
been successfully using these checklists
for many years. However, the recently
renewed interest in the use of checklists
suggests new ways to create and maintain
them. How should Certied Instrument
Specialist (CIS) technicians manage
checklists for instruments and/or supplies
to ensure a greater percentage of accu-
racy? They must take an active role in
understanding the process for creating
checklists and be very knowledgeable
about the procedures used to organize
and maintain them.
For example, there are several alternatives
available to optimize the required informa-
tion when creating preference cards in
either a Word document or as part of
Operating Room Management Software
(ORMS). Basic information will include:
Patient identifers
Date and time of the procedure
Facility and room number
Procedure(s) scheduled
Name of surgeon(s)
The individual item(s) to be pulled,
as well as the quantity required, will be
PATIENT HAS CONFIRMED
IDENTITY
SITE
PROCEDURE
CONSENT
SITE MARKED/NOT APPLICABLE
ANESTHESIA SAFETY CHECK COMPLETED
PULSE OXIMETER ON PATIENT AND FUNCTIONING
DOES PATIENT HAVE A:
KNOWN ALLERGY?
NO
YES
DIFFICULT AIRWAY/ASPIRATION RISK?
NO
YES, AND EQUIPMENT/ASSISTANCE AVAILABLE
RISK OF >500ML BLOOD LOSS
(7ML/KG IN CHILDREN)?
NO
YES, AND ADEQUATE INTRAVENOUS ACCESS
AND FLUIDS PLANNED
NURSE VERBALLY CONFIRMS WITH THE
TEAM:
THE NAME OF THE PROCEDURE RECORDED
THAT INSTRUMENT, SPONGE AND NEEDLE
COUNTS ARE CORRECT (OR NOT
APPLICABLE)
HOW THE SPECIMEN IS LABELLED
(INCLUDING PATIENT NAME)
WHETHER THERE ARE ANY EQUIPMENT
PROBLEMS TO BE ADDRESSED
SURGEON, ANESTHESIA PROFESSIONAL
AND NURSE REVIEW THE KEY CONCERNS
FOR RECOVERY AND MANAGEMENT
OF THIS PATIENT
SIGN IN
CONFIRM ALL TEAM MEMBERS HAVE
INTRODUCED THEMSELVES BY NAME AND
ROLE
SURGEON, ANESTHESIA PROFESSIONAL
AND NURSE VERBALLY CONFIRM
PATIENT
SITE
PROCEDURE
ANTICIPATED CRITICAL EVENTS
SURGEON REVIEWS: WHAT ARE THE
CRITICAL OR UNEXPECTED STEPS,
OPERATIVE DURATION, ANTICIPATED
BLOOD LOSS?
ANESTHESIA TEAM REVIEWS : ARE THERE
ANY PATIENT-SPECIFIC CONCERNS?
NURSING TEAM REVIEWS: HAS STERILITY
(INCLUDING INDICATOR RESULTS) BEEN
CONFIRMED? ARE THERE EQUIPMENT
ISSUES OR ANY CONCERNS?
HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
WITHIN THE LAST 60 MINUTES?
YES
NOT APPLICABLE
IS ESSENTIAL IMAGING DISPLAYED?
YES
NOT APPLICABLE
TIME OUT SIGN OUT
Before induction of anesthesia Before skin incision Before patient leaves operating room
SURGICAL SAFETY CHECKLIST (FIRST EDITION)
THIS CHECKLIST IS NOT INTENDED TO BE COMPREHENSIVE. ADDITIONS AND MODIFICATIONS TO FIT LOCAL PRACTICE ARE ENCOURAGED.
Figure 1: WHO Surgical Safety Checklist
CIS SELF-STUDY LESSON PLAN
listed in the preference card. An addition-
al column may inform OR staff that the
item is meant to be available but is being
held until the surgeon conrms the item
is needed.
The description of each item or instru-
ment should be carefully considered. For
example, some manufacturers descrip-
tions are not always clear or user-friendly.
OR and CSSD employees may use nick-
names or alias descriptions, and this can
result in confusion about which item is
needed for a specic case.
Checklists or preference cards for
instrument sets should allow for an alias
description to be included. Developing an
option on the checklist to print the man-
ufacturers and/or the alias description al-
lows the card to be customized. Including
the manufacturers catalog number and/
or bar code on the preference card pro-
vides an ideal method to conrm that the
correct product or instrument is pulled.
Including the storage location for each
line item on the preference card further
assures accuracy in pulling the correct
supply item for the case cart.
The order or sequence in which sup-
plies or instruments are listed should be
carefully considered. Most ORMS soft-
ware systems include options for group-
ing items by type or by location within
storage areas. Ideally, CSSD items will be
sequenced by location to expedite the
process of pulling supplies. Conversely,
sorting supplies by their type may expe-
dite the preparation of and charging for
supplies in the OR. Ideally, representatives
of both departments will collaborate to
determine a method that meets every-
ones needs.
For maximum effect, consider us-
ing comment elds available in ORMS
software. Comments may provide detail
at the individual line level or for groups
of supplies. Additional comments may
provide instructions specic to the OR
staff. Comment elds may also provide
directions for CIS technicians as they
organize items on the case cart or for the
OR staff to describe how supplies should
be treated during the case.
CIS technicians should participate in
the process of building and maintaining
instrument lists and preference cards. Un-
derstandably, the OR staff and physician
will determine the list of instruments and
supply items required; however, a process
must be in place to assess the items listed
and ensure accuracy. Including supplies
on the preference card that are not used
in the OR is highly unproductive for the
OR, as well as for CSSD personnel who
must pull and then restock unused sup-
plies in storage area. Developing guide-
lines or a methodology for removing
unused items creates greater prociency
for both departments.
CHECKLIST DEVELOPMENT TACTICS
Consider the following points to assure
maximum returns on the use of check-
lists, such as Instrument Tray Sheets or
Preference Cards:
1. The use of a checklist should be
mandatory. There should be no devi-
ation from the policy to use the list.
2. Develop the team. One of the critical
WHO requirements for the OR is to
pause before the procedure begins
and review the checklist. Each mem-
ber on the case states his or her name
and role, such as anesthesia staff, scrub
tech or circulating nurse. This tactic
enhances teamwork because each
member of the team is identied as
part of the team and will be critical to
a successful outcome. Note: CSSD
personnel, while not represented in
the OR during the procedure, are just
as critical to a successful outcome.
Developing healthy relationships
between OR and CSSD personnel
helps ensure that checklist details
contribute to the immediate avail-
ability of the correct case supplies
and instruments for the case.
3. Develop a method for periodic review
and updates for checklists. Corrobo-
rating with OR staff and/or managers
is essential to the success of this process.
4. Encourage CIS technicians to make
recommendations for improvements
in checklist design and suggestions
about items and/or comments to
include in the checklist.
5. When preference cards or other
checklists are created or updated,
CIS technicians should participate in the
process of building and maintaining instru-
ment lists and preference cards. Understand-
ably, the OR staff and physician will deter-
mine the list of instruments and supply items
required; however, a process must be in place
to assess the items listed and ensure accuracy.
CIS Self-Study Lesson Plan
collaboratively test (and test again!),
ideally with OR participation, to
assure that :
Wording is simple and precise
Language and layout is standardized
The layout is broken into meaning-
ful sections
The layout corresponds with
the order of items being pulled for
the case
The list has been tested
6. Incorporate a standard method for
two team members to sign off on
the instrument tray or preference
card checklist as case carts are
completed. This will assure a higher
degree of accuracy because a second
set of eyes provides verication.
7. Develop a method for tracking errors
related to instrument sets or case
cart completion. As common issues
are identied, methods for improve-
ment to the process or the checklist
may become known, and actions for
improvement can be taken.
8. Outline a method for communicating
any changes in checklists.
9. Train staff to use checklists during
their orientation as well as inservice
sessions.
1
CONCLUSION: A FINAL EXAMPLE
Checklists have proven their value by
catching mental lapses or lack of attention
where multiple distractions are inher-
ent. A great example in healthcare is the
checklist widely accepted for use when
inserting central venous catheters (CVSs;
commonly called central lines). Over
the years, the insertion of central lines in
patients to monitor vital signs and deliver
medications has become more common.
At the same time, the number of central
line associated bloodstream infections
(CLABIs) has increased dramatically.
The Centers for Disease Control and
Prevention (CDC) reports that as many
as 25% of patients contracting a CLABI
will die. The incidence of infections in
ICUs has dropped 58% since 2001, saving
lives and reducing costs. One reason: a
simple checklist was developed to help
ensure evidence-based best practices are
followed for every patient.
CSSD professionals should embrace
and more fully utilize existing checklists
and initiate other processes to assure
improved patient outcomes. One ideal
place to begin is to consider other rou-
tine CSSD operations that would merit
checklists.
REFERENCE
1. Atul Gawande. The Checklist Manifesto:
How to Get Things Right. Henry Holt and Com-
pany. 2010.
ADDITIONAL READINGS
OR Economics: A Hard-Wired Process for Prefer-
ence Card Review. MTORS Vol. 27, No 12,
pg. 11. December, 2011.
CDC Vital Signs. March, 2011.
IAHCSMM acknowledges the assistance of the
following two CSSD professionals who reviewed
this lesson plan:
LISA HUBER, BA, CRCST, ACE, FCS; Sterile
Processing Manager, Anderson Hospital,
Maryville, IL
PAULA VANDIVER, CRCST, CIS, CS Technician;
Orthopedic Specialist, Anderson Hospital,
Maryville, IL
Instrument Continuing Education (ICE) lessons
provide members with ongoing education in
the complex and ever-changing area of surgical
instrument care and handling. These lessons
are designed for CIS technicians, but can be of
value to any CRCST technician who works with
surgical instrumentation.
TECHNICAL EDITOR
CARLA MCDERMOTT, RN, ACE,
CRCST
Clinical Nurse III
South Florida Baptist Hospital
Plant City, FL
SERIES WRITER/EDITOR
JACK D. NINEMEIER, PH.D.
Michigan State University
East Lansing, MI
IAHCSMM is looking for volunteers to
write or contribute information for our
CIS Self-Study Lessons. Doing so is
a great way to contribute to your own
professional development, to your
Association, and to your Central Sterile
Supply Department peers.
Our Team will provide guidelines
and help you with the lesson to assure
it will be an enjoyable process. For more
information, please contact Elizabeth
Berrios (elizabeth@iahcsmm.org).
CIS SELF-STUDY
LESSON PLANS
CIS Self-Study Lesson Plan Quiz -
Checklists for Central Sterile Supply Departments
Sponsored by:
Lesson No. CIS 233 (Instrument Continuing Education - ICE) Lesson expires Sept. 2015
1. What is one reason for the increased importance
of checklists in modern healthcare operations?
a. They are required for federal government
reimbursements
b. They are required by healthcare insurance
organizations
c. They help busy healthcare providers
remember critical steps in a procedure
d. Checklists for processing procedures must
be led with the FDA
2. An instrument tray list or preference card is
a common example of a checklist used by
Central Sterile Supply Department personnel.
a. True
b. False
3. Which is not required information in a prefer-
ence card?
a. Patient identier
b. Facility and room number
c. Name of surgeon
d. Name of CIS technician pulling instruments
4. The use of nicknames and alias descriptions
can result in confusion about items needed for
a specic case.
a. True
b. False
5. What is an ideal method to conrm that the
correct product or instrument is pulled?
a. Include the manufacturers catalog number
b. Include bar code information
c. Include the storage location for each line item
d. A and B above
e. All the above
6. The best way to sequence CSSD items for
pulling is by:
a. Bar code number
b. Location
c. Manufacturers model number
d. Type of procedure
7. What is the ideal way to sequence instruments
to expedite the preparation of and charging for
supplies in OR room?
a. By bar code number
b. By type
c. By manufacturers model number
d. None of the above
8. CIS technicians should participate in the pro-
cess of developing and maintaining instrument
tray lists and preference cards.
a. True
b. False
9. Who determines the instruments and supply
items required for a procedure?
a. OR staff
b. Physician
c. CIS personnel
d. A and B above
e. All the above
10. There is little need to periodically review and
update checklists for specic types of procedures?
a. True
b. False
11. How many team members should sign-off on
an instrument tray list or preference card
checklist as case cards are completed?
a. One
b. Two
c. Three
d. The CSSD director and one CIS technician

12. When should staff be trained in the use of
checklists?
a. During orientation
b. During inservice sessions
c. Each day in a before-shift line-up session
d. A and B above
e. All the above
13. Using a checklist when inserting a Central Line
has reduced the number of Central Line
Associated Bloodstream Infections by:
a. 15%
b. 20%
c. 46%
d. 58%
14. CSSD personnel should be represented in
the operating room to comply with World Health
Organization (WHO) requirements for pre-
procedure introductions.
a. True
b. False

15. Including supplies on a preference card that
are not used in the OR is highly unproductive
for both the OR and for CSSD personnel.
a. True
b. False
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