Management of a Breach in the Sterile Field

A crucial component to reducing the likelihood of an infection acquired in healthcare settings – especially as they relate to surgical interventions – is the initiation and sustained maintenance of the sterile field. It is estimated that up to 70% of hospital acquired infections (HAI) are potentially preventable.¹ Sterile techniques, or the collection of behaviors and interventions which act to maintain the sterile field and reduce the potential introduction of contaminants, lower the risk of HAI.² Any breach in the sterile field must be managed carefully and promptly.

Given the importance of maintaining sterility throughout the duration of the procedure or intervention, it is imperative to know how to identify and respond to a breach in the sterile field. Common breaches include holes in wrappers that cause exposure of the intended, protected material to non-sterile environments, lack of filters, the introduction of organic material to a surgical or operative instrument which was previously sterile (e.g., introduction of hair, blood, or tissue), the introduction of non-sterile items to the sterile field (e.g., accidental dropping of a pen, glasses, or sweat), and the translocation of a sterile instrument into a non-sterile environment (e.g., sterile forceps being dropped onto the ground).³

Upon the introduction of a breach in sterility, sterility must be re-acquired as soon as possible. If an instrument becomes unsterile, it should be immediately removed along with any previously sterile objects that it contaminated. If a surgeon or proceduralist came into contact with the unsterile instrument, it is not necessary that the individual entirely re-initiate the process of becoming sterile themselves (i.e., the sterile scrubbing technique prior to the introducing of oneself in to the operating room) – rather, if only the individual’s gloves came into contact with the unsterile object, the gloves can and should be immediately exchanged. However, if the individual’s gown was touched, they should exchange their gown and likely re-initiate the process of self-sterility.³ Generally, anything which came into contact with the unsterile object(s) should immediately be removed from the sterile field, and anything (re-)introduced to the sterile field should be handled in a sterile fashion.

It has been noted that certain individuals express hesitancy in announcing a breach to the sterile field for one reason or another, whether that be fear of retaliation, a break in the evolution of the operation or procedure, or otherwise. It is important that these individuals speak up and voice their concerns regarding the breach in sterility, as a failure to reconcile this breach increases the likelihood of infection for the patient.³ The Association of Perioperative Registered Nurses has published suggested ways to introduce the discussion of a perceived breach in sterility. These include phrases beginning with “I am concerned,” “I am uncomfortable,” and “It is a safety issue.”³

In short, sterile technique refers to the collection of interventions and behaviors which serve to maintain an aseptic environment, ultimately reducing the likelihood of infection. It is imperative that any breach in the sterile field be announced, addressed, and reconciled before continuing with the original procedure or intervention. Individuals who are reluctant to announce breaches in sterility should be empowered to speak up and announce their concerns.

References

1. Bearman G, Doll M, Cooper K, Stevens MP. Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try? Curr Infect Dis Rep. 2019;21(1):2. doi:10.1007/s11908-019-0660-2

2. Speth J. Guidelines in Practice: Sterile Technique. AORN J. 2024;120(4):238-247. doi:10.1002/aorn.14219

3. Williams R. Dealing with Instrument Contamination and Speaking Up. Assoc Perioper Regist Nurses. Published online April 18, 2024. https://www.aorn.org/article/dealing-with-instrument-contamination-and-speaking-up