The Little Things Matter: Small Oversights That Can Lead to Joint Commission and DNV Findings in Sterile Processing

Sterile Processing professionals spend countless hours focusing on the complex aspects of instrument reprocessing—cleaning verification, sterilization monitoring, biological testing, documentation, and compliance with AAMI standards.

Yet many Joint Commission and DNV survey findings don't result from complex failures.

They result from the little things.

Small details that seem insignificant during a busy day can quickly become survey deficiencies and, more importantly, potential safety concerns.

The photo illustrates one of those examples perfectly.

A transport cart has been parked directly in front of a fire extinguisher cabinet, making immediate access difficult during an emergency.

While no one intentionally blocked the extinguisher, surveyors don't evaluate intent—they evaluate compliance and safety.

Every Small Detail Tells a Story

When surveyors walk through a Sterile Processing Department, they aren't just looking at sterilizers or instrument trays.

They're observing everything.

They ask themselves questions such as:

• Can staff respond safely during an emergency?

• Are exits and emergency equipment accessible?

• Are staff following established policies?

• Is the department organized and controlled?

• Are environmental conditions being maintained?

Often, these observations create the surveyor's first impression of the department.

Common "Little Things" That Can Become Survey Findings

Many of these issues take only seconds to correct.

Blocked Fire Extinguishers

As shown in the photo, equipment stored in front of the fire extinguishers prevents immediate access during an emergency.

The National Fire Protection Association (NFPA) requires fire extinguishers to remain readily accessible at all times.

Surveyors routinely notice:

• Carts

• Case carts

• Sterilization containers

• Supply boxes

• Carts are parked in front of extinguishers.

  
  

The fix is simple:

Never use emergency equipment locations for storage—even temporarily.

Blocked Electrical Panels

Electrical panels require working clearance.

Temporary storage often becomes permanent storage.

Surveyors frequently cite departments where carts or supplies obstruct electrical access.

Missing Ceiling Tiles

A missing or damaged ceiling tile may seem harmless.

In Sterile Processing, it represents a breach in environmental control.

One missing tile can quickly become a survey finding.

Improper Storage Heights

Sterile supplies stored:

• Too close to the floor

• Too close to the ceiling

• Against sprinkler heads

can all become deficiencies.

Storage requirements exist to protect package integrity and fire safety.

Unlabeled Bottles

Spray bottles without labels remain one of the easiest survey findings to prevent.

Every secondary container should be clearly labeled according to facility policy and OSHA requirements.

Dirty Wheels on Equipment

Case carts and transport equipment may have clean shelves while the wheels accumulate debris.

Surveyors notice overall cleanliness—not just instrument trays.

Damaged Walls and Floors

Small holes, peeling paint, damaged flooring, or cracked wall protection can interfere with environmental cleaning and infection prevention efforts.

Documentation Left Open

Quality records containing patient information or sterilization documentation left unattended can raise concerns regarding both privacy and document control.

Instruments Sitting Too Long Before Decontamination

Point-of-use care begins in the operating room.

Leaving contaminated instruments unattended without proper pretreatment increases cleaning difficulty and may violate facility policy.

Building a Culture of Continuous Awareness

The strongest Sterile Processing departments don't wait for survey week to clean up these small issues.

Instead, they create daily habits.

Consider ending each shift with a simple five-minute walkthrough.

Ask:

• Is every fire extinguisher accessible?

• Are exits clear?

• Are carts stored properly?

• Is anything blocking the electrical panels?

• Are ceiling tiles intact?

• Are chemicals labeled?

• Are counters clean?

• Are sterile storage areas organized?

Five minutes each day can prevent hours of corrective action later.

Survey Readiness Is About Habits

Joint Commission and DNV surveys rarely hinge on one major issue.

Instead, surveyors build confidence—or concern—based on dozens of small observations throughout the department.

When staff consistently pay attention to the little things, it demonstrates:

• Professionalism

• Accountability

• Ownership

• Safety awareness

• Pride in the department

Those characteristics are often just as important as technical knowledge.

Final Thoughts

Sterile Processing is built on precision.

The same attention to detail used to inspect an instrument should also apply to the department itself.

A cart parked in front of a fire extinguisher may seem like a minor oversight.

To a surveyor, it signals an opportunity to improve safety practices.

The good news is that these are some of the easiest problems to prevent.

Small corrections, made consistently, create a department that is always survey-ready—not just when inspectors arrive.

About Evolved Sterile Processing Consulting LLC

At Evolved Sterile Processing Consulting LLC, we help healthcare organizations identify both the obvious and the overlooked risks that impact compliance, operational efficiency, and patient safety. Our consultants bring decades of current, hands-on Sterile Processing leadership experience to every assessment, helping departments build sustainable processes that withstand Joint Commission, DNV, CMS, and AAMI scrutiny.

Real Experience. Proven Solutions.🌐 www.evolvedsterileprocessing.com📞 217-371-8488