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Solving the Unsolvable: Missing Instruments

How can a surgeon perform surgery without surgical instruments? It’s an obvious question, but it happens daily. Trays are sterilized missing instruments. Sometimes these are critical instruments. Often the OR staff does not know they are missing instruments until they open the tray and check the count sheet. Unfortunately, sometimes the OR surgical technician may not know an instrument is missing until the surgeon is at a critical point in surgery and the needed instrument is not there.

What are missing instruments?
A missing instrument is simply when a surgeon needs an instrument and it is not there. There are three types of missing instruments: nonrequested instruments, hidden missing instruments, and documented missing instruments. All three of these types of missing instruments have different root causes.

Nonrequested missing instruments happen when the surgeon or OR staff does not request the instrument. These are often specialty instruments that are peel packed for surgeon preference. The surgery starts, the OR requests the instrument, and the instrument cannot be found. This failure is sometimes caused by poor data on preference cards; the instrument is not listed on the preference card. More often, the SPD staff did not recognize the instrument after the last time it was used. The instrument was put on the backup wall where it is not unavailable for surgery.

Hidden missing instruments are tray errors. These are when SPD staff assembles trays missing instruments without documenting them missing. Sometimes this is caused by bad data, employees rushing because of heavy workload, and staff documenting the wrong instrument on a tray menu.

The type of missing instrument that happens most often is documented missing instruments. Documented missing instruments have become an everyday norm and frustration for most operating rooms. Sterile processing staff assembles sets, marks instruments missing, and sterilizes the tray. Little thought goes into if the missing instrument is critical or the surgical impact. There likely is no additional communication to the OR that the instrument is missing other than the label placed on the outside of the tray container. The OR staff complains because the instruments are missing and SPD responds, “Well, we marked it missing.” 

Documented missing instruments are typically caused by one of the following. Instruments are nonrepairable and removed from service. Without systems in place, replacement instruments are not ordered and OR staff may not know the instruments have been removed because of damage. However, the most frequent root cause of documented missing instruments is bad flow

Fixing flow can solve the unsolvable
How does bad flow create missing instruments? When trays get processed through decontamination and then assembled in a department with bad flow, critical instruments get left behind or wrong instruments are placed in trays. Typically, operating room staff does not sort instruments used in a surgical procedure back into the original trays. They count on SPD to reset the trays, getting the right instruments back in the right trays. Sterile processing departments typically fail this challenge because of bad data on count sheets or tray menus and poor flow.

The quickest way to make a big impact on a department’s missing instrument rate is by fixing bad flow.

For example, at General Hospital the operating room department primarily performs open heart procedures and general procedures. The open heart trays and laparoscopic trays are always prioritized because of the shortage of these expensive instruments. 

The first case of the day comes down from the OR and two trays are prioritized because they are one-of-a-kind trays. Then the laparoscopic trays are washed from the second case because they are also priority. The third case comes down and it is another open heart case with more one-of-a-kind trays. These trays are prioritized through decontam. 

Meanwhile, the priority trays from the first case are still sitting in assembly because they are missing instruments. The operating room staff did not sort the instruments correctly, and critical instruments needed to complete these one-of-a-kind trays are still on the case cart in decontam. Decontam and assembly are now backlogged, and no trays are getting sterilized.

Alternatively, the sets are assembled and sterilized because they are priority with critical instruments documented missing. These instruments may not get put back in the trays until the next time the tray comes through the department. The operating room receives instrument trays that are missing instruments.

Solution = One-piece flow
One-piece flow is where batch processing is replaced with one tray at a time flow. Add in first in, first out and miracles will start happening in a sterile processing department. Imagine that the first case cart was delivered to the sterile processing department, and the decontamination staff processed those instruments first. The instrument trays are processed in order, one by one. When the trays come out on the assembly side, the SPD staff only needs to search through the instruments from that case cart. They no longer have to wait until the end of the day for instruments to come out of the washers. The department is instantly unclogged and the missing instrument rate declines dramatically.

One-piece flow
One of the biggest impacts that can be made to a sterile processing department is flow. Have a problem with trays being unavailable? Look at flow. Struggling with missing instruments? Look at flow. Have backlogged and frustrated staff? Well, flow can fix that, too.

Consider an organization where there is insufficient washer capacity. Because of the insufficient equipment capacity, the staff takes several dangerous shortcuts to get the instruments processed. Vendor trays go straight into the sterilizers with no decontamination. The containers get a quick rinse in the sink and then go into a sterilizer for sanitation. Surgical site infections climb and the department gets more backlogged because the sterile processing technicians keep taking more and more shortcuts to get the work through.

Consider an organization where there is insufficient instrumentation. Because of the insufficient instrumentation, the staff takes several dangerous shortcuts to get the instruments processed. Priority trays get pulled off of case carts and pushed through the washer with no manual cleaning. Sonication routinely gets skipped for these high-priority trays. Trays get wrapped as soon as they come out of the washer with no inspection, bioburden and all. Surgical site infections climb and the department gets more and more backlogged because the sterile processing technicians keep taking more and more shortcuts to get the trays through.

Consider an organization where there is sufficient washer capacity and instrumentation. The sterile processing staff pulls the trays they prefer to wash off of the case carts and sends them through the washers. Difficult-to-clean instrumentation gets left behind. Priority trays get processed while lower priority trays get left in decontam. Assembly staff prepares to assemble the priority trays, but half the instruments are missing; they are still on the case cart in decontam. The surgeons are frustrated because their critical priority trays are incomplete or missing instruments. The sterile processing department is getting further backlogged and takes more and more shortcuts to get the work through. The tray error rate and missing instrument rate climbs.

What do all three of these departments have in common? Bad flow. There may be different reasons and causes for bad flow. Sometimes it is the design of the department, insufficient equipment, insufficient staff, not enough trays, or simply a low-engaged crew, but the effect is typically the same. Symptoms of bad flow are backlogged trays, high error rates, missing instruments, disengaged sterile processing staff, and an unhappy operating room.

Implementing one-piece flow
Implementing one-piece flow has its challenges; however, there are several things that can be done to ensure success. A well-designed department can hardwire flow. Decontam should be designed with a sink, sonic, washer flow. This ensures that trays move seamlessly in a one-piece flow to the washers. Assembly workstations should be located close to the washer unloading area and staff should work on the trays coming out of the washers in the order they are received. Hand-washed items should have a similarly structured flow. Equipment and work areas should be physically organized in a one-way design that matches the manufacturer instructions for use. This design will hardwire in the processes to match the flow. 

Sufficient tray inventory must exist for one-piece flow to succeed. 

If a department is not well designed, a Kanban system or visual indicator system can help support one-piece flow until future renovations can occur. For example, a quick and easy solution is to color tag all of the trays from a case cart with the same tag. Rotate colors as the day progresses. The tag should be from a vendor that has validation testing to ensure it can be washed and sterilized. If all the trays from a case cart are tagged the same color, staff can then process them through the washers together. On the assembly side, prep and pack technicians must search only in the trays with the same color coding. When they are missing instruments in their tray, they can quickly find the instrument to get the trays complete and in service. 

Implementing one-piece flow will solve the unsolvable. Most missing instruments are missing because trays are mixed. A one-piece flow system reduces the search time by ensuring that all trays from the case cart that were used together are assembled together. This means fewer instruments are marked missing because staff can find them.

Solve the unsolvable, implement one-piece flow.

Note: This article represents the opinion of the author and is not representative of any organization the author is affiliated with.


Marjorie Wall is a director of sterile processing at Kaiser Permanente and IAHCSMM board of directors member. As a sterile processing leader with over 20 years of industry experience, Marjorie pushes the boundaries for change and innovation in her organization and in the industry. Marjorie built her career turning around underperforming departments and is now an industry change driver as a writer and keynote speaker.

Marjorie has achieved a masters of organizational leadership from Azusa Pacific University, CRCST, CIS, and CHL certifications from IAHCSMM, and Six Sigma Black Belt Certification from the American Society for Quality. Marjorie has personally developed 12 frontline staff into SPD leaders and 13 SPD techs into Six Sigma Yellow Belts. 

Marjorie Wall’s life philosophy is, “Sometimes you have to take a leap and build your wings on the way down.” We have to be willing to change and improve through the toughest challenges. We have to lead SPD.

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