Back in 2014, The Joint Commission addressed the issue of improperly sterilized or high-level disinfected equipment with Quick Safety Issue 2. Four years later, this topic continues to be a major concern.

Standard IC.02.02.01 requires organizations to reduce the risk of infections associated with medical equipment, devices and supplies. Noncompliance rates for this standard have risen every year from 2009-2016 for Joint Commission-accredited hospitals, critical access hospitals, ambulatory and office-based surgery facilities.1

Even further, the Joint Commission found that from 2013-2016, immediate threat to life declarations directly related to improperly sterilized or HLD equipment increased significantly.  In fact, 74% of all ITLs in 2016 were related to improperly sterilized or HLD equipment.

In Quick Safety Issue 33, the Joint Commission’s Office of Quality and Patient Safety lists some of their findings from non-complying organizations. Here are a few of the highlights:

Non-compliance Findings
  • Staff lack the knowledge or training required to properly sterilize or HLD equipment
  • Processes for sterilization or HLD are not followed (i.e., staff take shortcuts)
  • The time frames for proper sterilization or HLD of equipment are not followed
  • Lack of monitoring or documentation of sterilization or HLD of equipment, which makes it difficult to track the use of equipment on a specific patient, complicating the patient notification process when an outbreak occurs
  • Equipment is spread throughout the facility and may be processed or stored in numerous locations, making it difficult to track the equipment for documentation purposes

In the same Quick Safety issue, the Joint Commission provides a checklist of safety actions to consider in order to help protect patients from the transmission of disease and bacterial agents. Here are the highlights:

Safety Actions to Consider 
  • Competency and Training – assure that staff who perform HLD and sterilization have been trained and are deemed competent to do so AND those with supervisory oversight are competent to sign-off and monitor staff conducting HLD or sterilization
  • Manufacturer’s Instructions for Use – assure staff have access to both the manufacturer instructions for use on instruments, equipment and supplies used to HLD or sterilize.
  • Quality Monitoring – assure that HLD and sterilization quality control requirements are rigidly followed and documented.



25+ Powerful FOMO Statistics to Skyrocket Sales (2020). January 3, 2020.

ANSI/AAMI ST79, Comprehensive guide to steam sterilization and sterility assurance in health care facilities. 2017

AST Guidelines for Best Practices for Laundering Scrub Attire. April 14, 2017.

Laundry and textile hygiene in healthcare and beyond. July 1, 2019.

Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. March 31, 2015.

Study of bacterial flora associated with mobile phones of healthcare workers and non-healthcare workers. June 9, 2017.

Learn what to be aware of when moving from manual instrument management to automated

Download ebook


If you like this post, check out these:

  • 1Improperly sterilized or HLD equipment – a growing problem. (2017, May). Quick Safety33. Retrieved from