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Section 8.0E STERILIZERS Page 4. <br />* Load Logs /Documentation <br />A written record for all cycles ran must be kept at all times to comply with <br />regulations from the State — Title 22, JCAHO and Environmental Health. <br />A weekly graph must be present showing all cycles ran for each day in that <br />corresponding week. The graph must contain the signature and date of the <br />sterilizer operator against each cycle. In the event of a failed cycle there must be a <br />notation against the cycle graphic explaining the action taken by the operator. <br />A daily log sheet must be kept indicating time, temperature and any problems <br />during each cycle. (See attached). <br />Should a cycle fail the date, reason for failure, cycle number if present, time and <br />operator name must be recorded on the log sheet. The action taken by the operator <br />when a cycle has failed must also be recorded. <br />The sterilization records, graphs and log sheets must be kept in storage in <br />accordance with the State Title 22 regulations. <br />5. Equipment Testinja & Maintenance <br />Biological Monitoring <br />Although there are automatic controls built into the Autoclaves, which control the <br />temperature and time of the cycles to achieve sterility, there are many factors, <br />which could hinder the sterilization of items inside the Autoclave chamber. To <br />obtain a reliable assurance check Biological Indicators are used to test <br />effectiveness of the sterilization cycle inside the chamber. <br />The Biological Indicators are a live culture of Baccidio . The indicator is placed <br />into the Autoclave chamber with a load requiring sterilization. After the cycle is <br />completed the indicator is incubated for a certain of time to see if the live culture <br />was successfully destroyed. If the indicator shows a growth or positive culture <br />this shows that the items inside the Autoclave chamber were not sterilized <br />effectively. <br />* Documentation of Tests <br />Biological Indicator tests must be performed once a day and test results recorded. <br />Once the test results have been obtained the sterilization load can be considered <br />