Laserfiche WebLink
• <br />Kaiser Permanente Stockton <br />Environmental Services <br />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: SANT-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, 07/20/06 <br />POLICY: Evidence of an effective sterilization process will be documented. <br />Rationale: In compliance with the Medical Waste Management Act, and California State and County <br />regulations, this process ensures that monthly biological indicator testing of treated medical waste <br />occurs to ensure that medical waste treated on-site is rendered non-infectious. All Engineering <br />Personnel will follow this procedure for sterilizing, incubating and reading of biological indicators. <br />THIS PROCEDURE WILL BE PERFORMED MONTHLY ON THE 20TH OF EACH <br />MONTH, OR ON THE 18TH OR 19TH IF THE 20TH FALLS ON A WEEKEND OR <br />HOLIDAY. <br />PROCEDURE: <br />1. The 3MTM AttestTM Auto -reader is housed in the Laboratory Microbiology Section. Always leave <br />the 3MTM AttestTM Auto -reader plugged in. If found unplugged, allow 30 minutes warm up time. <br />2. Utilize Biological Indicator 1296 Rapid Readout tubes. <br />3. Always wear Personal Protective Equipment (PPE), when operating the machine. <br />• Safety Goggles <br />• Heat Resistant Gloves <br />4. The Chief Engineer verifies the 3M Biological Indicator Test Pack and the Control Spore Tube <br />are from the same manufacturer. The date and the lot number for each 3M Biological Indicator <br />Test Pack and Control Spore Tube are verified prior to giving the 3M Biological Indicator Test <br />Pack to the Engineer who will autoclave the 3M Biological Indicator Test Pack with the <br />infectious waste load. If the lot number indicates that the 3M Biological Test Packs have expired, <br />they are not to be used, and the Sani-Pak Medical Waste Sterilizer is to be taken out of service <br />until new replacement Test Packs have been received. Notify the Safety Manager or Safety <br />Officer, the Engineering Department, the Environmental Services Manager, and the <br />Reviewed by Nursing Department Approved by Facility P&P Committee Meeting 5/13/04 <br />P:\MyDocs\QuahtyUoAnn\Policies\Updated Policies\Urgent-Emergent Triage 6.8 <br />9 <br />