An essential part of reprocessing medical instruments and devices is the use of chemical detergents during soaks and other processes. It is critical to ensure that the proper amount of chemical is present in the solution to remove soil from the contaminated surfaces. Our team has made observations where staff are not ensuring that the proper amount of detergent is mixed with the proper amount of water to create the dilution ratio set by the manufacturer’s instructions for use (IFU). Improper ratios result in an ineffective solution or a concentration that may actually damage the equipment. For example, one consultant discovered that the proper detergent/water mix was half of what was listed in the IFU making the solution potentially ineffective in removing soil or germs. Here are some of the observations we have made regarding detergent soak solution dilution:
- Often staff are relying on automatic dispensers to release the proper amount of detergent into the prefilled sink. However, the dispensers have not been serviced according to the IFU to ensure calibration has been maintained. Staff are also not manually verifying the dispensed amount as recommended by the IFU.
- Staff are not aware of the amount of water to fill in the sink for soaks or have not verified that the designated fill line is accurate. Additionally, staff have not performed accurate calculations on the amount of detergent to the amount of water. (Always check your math!)
- Staff are using calculations of detergent/water mix based on a previous product that was used. The organization went with a new detergent where the mix ratio was different but staff were using the old calculation.
We recommend that organizations:
- Develop a process to verify detergent/water mix based on the IFU and their risk assessment of the process.
- Ensure that all automatic dispensers are maintained according to their IFU to maintain accuracy.
- Validate fill lines in sinks and any other type of vessel and ensure that they are marked clearly.
- Provide staff with the correct type of measuring equipment to ensure accuracy when manual measurement is required.
- Ensure that changes with detergents are reviewed for changes in mix ratios. Modify procedures as needed and ensure staff are trained.
- Create written processes and procedures for detergent/water mix, post them at point of use and ensure staff are trained and competent.
- Incorporate review of dilution procedures during leadership rounds.
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
