The design of medical devices, equipment, and instruments can provide ideal spaces for bioburden accumulation and subsequent development of surface biofilms, especially if compound hinges, gaps, channels, or lumens are present. Many outcomes related to the use of poor-quality instruments are likely to go unrecognized, especially if the result of an event is latent in a patient's course. To increase knowledge about the prevalence of reported events related to issues with surgical instruments, Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for acute care events associated with bioburden on surgical instruments reported from January 1, 2005, through December 31, 2015. Analysts then compared the results with Pennsylvania Health Care Cost Containment Council (PHC4) acute-care procedural denominator data from the same time frame. The results show an increase in the number of reported events over time, both in the number of reports per year and as a rate per 1,000 procedures. To combat the trend of increased bioburden prevalence, a quality improvement initiative in surgical instrument reprocessing may need to occur. The operating room and its patients depend on the reprocessing department; operating room services simply cannot exist without an adequate flow of clean and sterile surgical instruments and equipment. Efforts should be considered to unify departments and processes around the care and maintenance of mission-critical items, such as surgical instruments, devices, and equipment.
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