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SX34 - Surgery – Sterilization of Equipment

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Purpose: To establish a consistent approach in achieving the highest level of asepsis with each sterilizing task

Timeline: Training on the importance of asepsis and the use of all pieces of equipment used for sterilization is implemented upon hire. Updates are reviewed as necessary.

Team Member Responsible: The designated practice team member(s) responsible for completing the task(s) outlined in the protocol

Supervisor/Point Person: The practice team member(s) responsible for managing the implementation of the protocol



  • Define sterility shelf life for gas and steam sterilization, as well as instrument packs and individual instrument pouches
  • List the type and brand of sterility indicator or integrators that are used (i.e., they measure time, temperature and pressure)
  • Define the rotation of packs and instruments (i.e., the most current date is used last)
  • Define a schedule for checking and resterilizing instruments and packs (i.e., practice team member who is responsible, how often this is done, etc.)
  • Define a process for identifying which instruments go in which surgical packs (i.e., color code bands on the instruments)
  • Outline a procedure for inspecting instruments for defects, wear and/or contaminants
  • Define the location for packs and instruments (i.e., enclosed cabinet that is free of airflow, moisture and other contaminants)
  • Define a process for washing and drying linens
  • Define when linens are to be discarded (i.e., torn or shredding fibers)
  • Define what is identified on the outside of packs, including:
    • Date
    • Contents or pack identification
    • Initials of the person that assembled the pack


  • Define the procedure for autoclaving, such as:
    • Cleaning process
    • Cleaning schedule
    • Practice team member(s) responsible
  • Outline the necessary training areas for the autoclave, such as:
    • Maintenance
    • Cleaning
    • Type of water used
    • Practice team member(s) responsible

Gas Sterilizer/Ethylene Oxide

  • Define the procedure for gas sterilization, such as:
    • Approved safety program
    • Precautions
    • Safety hazards
    • Authorized practice team member(s)

Any Other Types of Sterilizer

  • Define necessary training and practice team member(s) responsible for this
  • Define cleaning and/or maintenance procedures
  • Define any unique safety procedures and/or hazards

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