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Patient 1
PRIOR TO THE REPORTED EVENT, FACILITY PERSONNEL IDENTIFIED A "FILL TIME" ERROR ASSOCIATED WITH THEIR SYSTEM 1E PROCESSOR AND REMOVED THE UNIT FROM SERVICE FOR REPAIR. FORGETTING THAT THE UNIT WAS OUT OF SERVICE, AN EMPLOYEE INSERTED AN S40 STERILANT CUP INTO THE SYSTEM 1E PROCESSOR. MOMENTS LATER, THE EMPLOYEE REALIZED THAT THE UNIT WAS NOT IN SERVICE AND REMOVED THE FULL PUNCTURED CUP OF STERILANT FROM THE UNIT WITHOUT PROPER PPE. THE EMPLOYEE REMOVED THE STERILANT CUP FROM THE UNIT WHICH RESULTED IN A SMALL AMOUNT OF STERILANT CONTACTING THE EMPLOYEE'S FINGER. THE OPERATOR MANUAL STATES THE PROPER PPE REQUIRED WHEN DISPOSING OF THE S40 STERILANT CUP, "TO DISPOSE OF PARTIALLY FILLED, LEAKING, DAMAGED, OR EXPIRED STERILANT CONTAINERS, PUT ON APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT (CHEMICAL-RESISTANT GLOVES, APRON, GOGGLES OR FACE SHIELD, AND ANY OTHER PROTECTION REQUIRED BY FACILITY PROCEDURES). WEAR PROTECTIVE ATTIRE FOR THE ENTIRE PROCEDURE." A STERIS SERVICE TECHNICIAN ARRIVED ONSITE AND INSPECTED THE UNIT. THE TECHNICIAN MADE THE APPROPRIATE REPAIRS TO ADDRESS THE FILL TIME ERROR, COMPLETED PREVENTIVE MAINTENANCE ACTIVITIES, RAN A TEST CYCLE, AND RETURNED THE UNIT TO SERVICE. WHILE ONSITE, THE TECHNICIAN COUNSELED FACILITY PERSONNEL ON PROPER USE AND OPERATION OF THE SYSTEM 1E PROCESSOR AND S40 STERILANT, SPECIFICALLY, THE IMPORTANCE OF WEARING PROPER PPE. NO ADDITIONAL ISSUES HAVE BEEN REPORTED.