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Kaiser Permanente Stockton <br />• <br />Environmental Services <br />"Sm p 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, 07/20/06 <br />• In the event of a positive test result, the same load will be run only one additional time using a <br />new 3M Biological Indicator Test Pack. After incubation, if the sterilized tube result is also <br />positive, the Engineering Department will schedule repairs (internal or contact Sani-Pak ), and <br />this load and all untreated infectious waste will be placed in Stericycle Tubs for off-site waste <br />treatment until the Sani-Pak is operational again. <br />All positive test results must be reported immediately to the Chief Engineer, the EH&S <br />Manager, and the Environmental Services Manager. <br />• Do not run additional loads until further testing shows a negative result. <br />Recording the Results <br />The Record Log Book is located in the Engineering Office, and the 3MTM AttestTM Auto - <br />Reader is located in the Laboratory Microbiology Section. <br />Record the test results in the Record Log Book. <br />Record the lot number/expiration date of the biological indicator tube and control tube in the <br />log book. <br />After recording result, place tube into a red sharps container. <br />Reviewed by Nursing Department Approved by Facility P&P Conutvttee Meeting 5/13/04 <br />P:\MyDocs\Quality\/oAnn\PoGcies\Updated Policies\Urgent-Emergent Triage 6.8 <br />