Scenario—Central Sterile Supply Department
In the Central Sterile Supply Department (CSSD) of a large metropolitan hospital, enrolled nurses are
required to prepare and pack theatre trays for sterilisation and dispatch to the hospital’s operating theatres.
The procedure requires the nurses to bend over a large, deep sink to wash various steel instruments and
trays in warm soapy water. The tiled floors in front of the sink are often wet, and slips are not uncommon.
After washing and drying the instruments and trays, the nurses package them according to the theatre’s
requirements. The nurses wrap the packages of varying sizes and weights in cloth and carry them from the
preparation area to the high temperature sterilisers, and lift them onto racks for sterilisation.
On completion of the sterilisation process, the nurses remove the trays from the steriliser and carry them
past the preparation bench to load them onto trolleys for transfer to the theatre.
Due to budget cuts some months earlier, the number of CSSD staff has been reduced by three. However,
due to increasing waiting lists for elective surgery, the hospital administrators have decided to increase the
number of operations carried out by 15%. As a result, a nurse’s assistant was employed two days before the
scheduled increase in theatre use.
The increased workloads meant that the nurses were unable to provide a formal job induction to the new
employee. The employee was assigned the job of packing the washed instruments onto the trays using a
checklist. In the theatre, staff were finding incorrect instruments packed onto the trays.