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The Missing Instrument Board

Are you still a paper-based department? If you’re wondering what I mean by that, I’m asking if you are computerized or are you even lucky enough to have a surgical instrument asset-management system (commonly referred to as an instrument-tracking system). Typically, when I ask audiences how many people have these systems, it’s less than 20%. These systems are wonderful if we have them, and they bring a lot to the table for the department terms of accuracy, efficiency, and productivity. For the rest of you who do not have these systems, we have to come up with processes that we can do on paper or manually if needed.

In this article, we will focus on what to do when we have missing instruments in our sets on assembly. We will present you with a manual way of ensuring that these crucial pieces are placed back into the sets so that we can have 100% complete and accurate instrument sets.

Establishing ground rules
We have to do our best to have complete instrument sets. Technicians need to understand this on assembly. When there is a missing instrument from the set, there needs to be standard operating procedures (SOP) as to what the steps are for the process of replacing the instrument. Consistency is always key and we want to try to have technicians taking the same pathways so we are all on the same page.

We used the term “go fish” in my previous department when a set came through the washer and was missing an item and we were not really sure where the missing instrument could be. We would ask our fellow assembly technicians and when an instrument was missing, they would say “go fish,” then we would check with our decontamination technician. This is more crucial than most people consider because if we really back-trace this instrument, it could have been left behind and potentially left in the patient. In this scenario, the SOP should include contacting the OR as soon as possible to inform them that there is potentially a missing instrument and to question the team. This ensures that we do have any retained instruments inside of patients. This is why it’s important to include your external customer in the development of the SOP.

Replacement of the instrument
Once it’s determined that the instrument is actually missing, the SOP should guide us to replace it, if possible. Of course, we should look at the backup instrument area. Check with the lead technician or supervisor about whether we should open a peel pack of instruments for replacement. We must remember to check all of our usual locations, including outside of the department. 

Missing stickers
Prior to the development of this SOP, we would have discovered a missing instrument and simply made a missing sticker, placed it on the set, and then continued on our merry way. This is now no longer the case. It is only after exhausting all of our resources and following our procedure that we determine that the instrument is truly missing. This is also where new opportunities for improvement can come in. This is a great time to evaluate what information goes on your missing sticker. I suggest including the name and part number of the instrument, the set name and number that it is missing from, and the date and initials of the technician on the missing sticker. Under this new and improved procedure, it is only when there is a genuine missing instrument that the technician will create a missing sticker. When they do, they will make two missing stickers. One will be placed on the set according to whatever the hospital procedure is, and the second one will be placed on the missing board.

The missing board
The missing board is a physical board and can be either on an existing dry erase board or on a large easel pad. It is best to separate it in vertical columns by services. Services can flow from left to right alphabetically. So your board may start with Cardiac, and the next column is ENT, followed by General. It all depends on your specialties in your facility. The technician approaches the board, looks for the appropriate service, and places the second missing sticker under that column.

The missing board should be in a convenient area not too far away from the assembly area because one of the other goals in assembly is to keep assemblers assembling. Every time we pull a technician away from the work at hand, there’s the potential for error.

Reorder point
Someone in the department is responsible for reordering surgical instruments, even if that consists of simply passing the information along to an ordering agent. It’s important to work this into your process. All of the instruments that are needed will be on this board. When we ran our board, the person responsible for ordering would check the board daily at a minimum, reorder what was necessary, and then write next to the sticker on the dry erase board “on order.” One small step of redundancy is that if the set is missing an instrument for a number of days, the same instrument missing sticker is going to be generated.

The technicians continue to generate stickers and when they approach the missing board, they stack the duplicate sticker on top of the existing one. When the missing instrument orders finally arrive, the inventory person hands them to the supervisor or the lead tech, who then looks at the missing board and determines which sets they belong to and removes the sticker from the missing board. At this point, if you are a more advanced department and have service leaders, they can be handed off to those service leaders who then complete the sets.

Information gathered from the process
This process opens up a number of wonderful opportunities for the department, which I will pose in a Q&A.

Q: Outside of these known missings, where are all the others?
A: Most hospital instrument replacement budgets are fairly large. The dollars can be either on a separate line item on the budget or mixed in with the new instrument replacement budget line. If you have a robust repair program in the department, you should be able to tell how many instruments go out for repair and come back beyond repair. This is an important number to get to know. Once we know how many new instruments were purchased we can then deduct the replacements from the total. This essentially tells us how many lost instruments there were.

Q: Are they going into the trash in the OR? Is it always the same team in the same rooms?
A: This particular scenario opens up a wonderful opportunity to work directly with your customer and try to get to the root cause as to where these instruments are possibly going.

Q: Why are there not any backups in the instrument backup area?
A: The inventory person may need to adjust the par levels on hand or check on them more frequently. If you have a fully developed relationship with your primary instrument vendor, you can work with them to consign the top 20 instrument patterns to the backup shelf in the dept. You can establish a par level of 20 each on the backup hook. When your inventory par level counts are done you can cut an invoice for the missing amount. For example, you go to the hook and there are only 10 Kelly clamps. You pay for the 10 you used and replace them on the hook.

There is no doubt that what seems like a simple process of replacing a missing instrument can certainly be much larger than anyone thought and have far-reaching tentacles throughout the entire process. As many questions as this process may generate, consider them as many opportunities for improvement for you, your team, and for what is ultimately most important—the greatest patient safety possible.


David Jagrosse, CRCST, CHL, has 30 years of experience in CSSD/SPD as a technician, supervisor, and manager. He was the Connecticut Central Service Association communications officer (1998–2000), vice president (2006–2008), and served three terms as president (2009–2015). David was a member and chairman of the ASHCSP Recognition Committee. He works with the AAMI Standards Work Group 40 (ST79) as an active voting member that develops guidelines in CSSD, and is the director of the oneSOURCE Speakers Bureau. David is active with IAHCSMM as a member of the orthopedic council and speaker at annual meetings, and has served IAHCSMM in many capacities, including president (2015–2016). He has been published in Communiqué/Process, Infection Control Today, Healthcare Purchasing News, and AAMI Horizons. David is a consultant for AAMI-based audits to CSS/OR audiences internationally.


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