A surgical technician prepares her back table for the next laparoscopic surgery. Instruments are removed from their containers and packages, and placed neatly on the back table. Chemical indicators show that sets and instruments are sterilized; the patient is prepped. The surgeon begins the procedure. It progresses smoothly until a particular dissector is requested. The surgeon takes hold of the grasper to place it in the port, and then notices blood dripping from it into the port. The blood must have come from the last patient, because the surgeon hasn’t used this instrument yet. Clearly, it was not disassembled or sterilized.

Lesson: Just because the sterilizer was capable of sterilizing doesn’t mean it did so. Sometimes technicians or personnel don’t disassemble graspers because they don’t know that they are made to come apart or how to disassemble them. Sometimes techs are requested to keep them together for any number of reasons. 

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