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• <br />Kaiser Permanente Stockton <br />Environmental Services <br />KAISER PC-ti11AANEIV7'E FACILITY POLICY AND PROCEDURE <br />TITLE: 3M Tm Attest Biological Indicator Sterile <br />Approval Date: 5/13/04 <br />Processing Policy and Procedure <br />Approving Committee: Facilities P&P <br />1) ATTACHMENTS: None <br />SUBJECT: SANI-PAK SPORE TESTING <br />ORGINAL DATE: 5/13/04 <br />LAST REVIEW DATE: <br />REVIEW INTERVAL: Every Three years/As Needed <br />Basis <br />NEXT REVIEW DATE: <br />LAST REVISED DATE: 7/29/04, 07/05/06 <br />Notify the Safety Manager or Safety Officer, the Engineering Department, and the Administrative <br />Services Director for Environmental Services of same. (Example: lot # 2003-1 AK, which means <br />the lot expires January 31, 2003- see picture below.) <br />5. Also, the Monthly Medical Waste Management Checklist will be completed the first Friday of <br />each month verifying the expiration date of all 3M Biological Indicator Test Packs. This <br />document is signed by the Environmental Services Manager and by the EVS Administrative <br />Specialist. <br />6. The Sani-Pak Operator loads the Sani-Pak chamber half way with red bags enclosed in <br />autoclavable bags. (Each autoclave bag must be punctured for ventilation). Place 3M Biological <br />Indicator Test Pack on top bag in the center of the load. Run cycle. <br />7. The Sani-Pak Operator removes the sterilized 3M Biological Indicator Test Pack from the Sani- <br />Pak and the 3M Biological Indicator Test Pack is allowed to cool prior to handling and <br />processing. <br />8. THE CURRENT STERILIZED LOAD IS TO BE LEFT IN THE SANI-PAK CHAMBER <br />UNTIL THE INCUBATION TEST RESULT IS CONFIRMED TO BE NEGATIVE. <br />Reviewed by Nursing Department Approved by Facility P&P Conanittee Meeting 5/13/04 <br />P:\MyDocs\QualityUoAnn\Policies\Updated Policies\Urgent-Emergent Triage 6.8 <br />