Key Points

Please take a moment to review these points, reflect on their significance and consider how they apply to your own experiences.

Tick to confirm (optional):

• Stop patient care if a disinfection step was missed and reprocess the device immediately using the correct method and contact time.
• Perform a rapid risk assessment to determine whether exposure was minimal or requires escalation to a line manager and IPC advice.
• Document who identified the lapse, immediate actions taken, timing, patient notification decisions and rationale for chosen workflow changes.
• Containment steps: remove affected items from circulation, clean and disinfect all touch points, and segregate cleaned vs used equipment.
• Implement system fixes such as visible 'cleaned' and 'used' bins, room-reset checklists, peak-period second checkers and brief coaching.
• Schedule a review date and brief audit to confirm the fix reduced recurrence and record learning for the team.