Reducing Surgical Instrument Contamination Through Multidisciplinary Quality Improvement: A Systems Approach at an Academic Medical Center
Kamga Nkouli, Emily Tally, James Lutz, Nina Dao, Robert Rusco, Kaitlin Marshall, Wendy Seiger, Lisa Case, Michael Morrey, Andrew JeaBackground:
In early 2025, OU Health identified an increase in contaminated surgical instrument sets reaching the operating room (OR). Contaminants, including bioburden, hair, holes in wrapping, debris, and wet sets, posed risks to patient safety, workflow efficiency, and OR productivity, suggesting systemic deficiencies across the sterile processing department (SPD) and perioperative workflow.
Methods:
We convened a multidisciplinary quality-improvement team comprising administrators, surgeons, nurses, scrub technicians, SPD technicians, and quality specialists. Using the 8-Step methodology, we conducted root cause analysis, process mapping, and longitudinal data tracking. Interventions included standardized point-of-use cleaning, enhanced SPD personal protective equipment and gowning practices, washer maintenance, adoption of heavier wrapping materials, containerization of high-risk sets, limiting tray weight, removal of static-attracting materials, and targeted staff education.
Results:
From July 1, 2025, through January 31, 2026, 388 contamination events were recorded across service lines. Neurosurgery accounted for 36% (136 events) of all events. Common contamination types were holes (113 events), debris (98), bioburden (51), and filter defects (28); hair (20), wet sets (15), and improper disassembly (15) were less common but clinically significant. Temporal analysis demonstrated intermittent short-term improvements but persistent recurrence across contamination types. Contaminated sets contributed to 57% of all documented OR delays, totaling 2851 minutes. Estimated direct costs were $176 762; projected annual costs were $589 042.
Conclusions:
Contaminated surgical instrument sets represented a recurrent systems-level failure. Institution-wide efforts, including multidisciplinary collaboration, structured quality-improvement methodology, and targeted interventions, produced measurable improvements. Continued monitoring, workforce competency reinforcement, and system redesign are needed to mitigate future risk.