The purpose of this research study was to determine whether toxicity levels differed between instrument sets sterilized without paper and those sterilized with paper having laser print. Undesirable outcomes in complex systems, such as health care delivery, are usually the effect of compound latent errors in the system that influence individuals in the system to, in turn, make acute errors leading to adverse events (Linkin et al., 2005). For instance, the sterilization of instruments with toxic substances on them can lead to patient infections, morbidity, and or mortality. Invasive surgeries conducted with inadequately sterilized instruments present the possibility of infection transmission of such pathogens as HIV and hepatitis B virus, and toxic chemicals (Linkin et al., 2005). As a result of the potential wide spread effect of instrumentation sterilized within healthcare facilities, checks and balances must be applied to the sterilization process to help eliminate patient safety issues (Miller, Plamondon, Phillips, & Spencer, 1997; Palenik, 2006). Thus, this study explored whether residual toxic contaminants were transferred to instrumentation from count sheets with laser print. Instrument sets were exposed to ink laden paper, steam sterilized, extracted, and tested for cytotoxicity.
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