Operational Excellence

Document Type


Publication Date



Maine Medical Center

MeSH Headings

Frustration, Surgeons, Surgical Instruments, Patient Care, Replantation


In an academic tertiary medical care center, the OR was receiving incomplete instrument trays. This issue became increasingly problematic in wasted staff time and cost to the institution.

Using a tracking system to generate a missing instrument report, baseline metrics were established. Reviewing each report, an interdepartmental team comprised of members of the OR and sterile processing departments, initiated a number of countermeasures.

Since the start of these countermeasures, there has been a reduction in the receipt of incomplete OR trays. Next steps include creating a tag process by which the OR instrument trays from one case would be kept together during the cleaning, prepping and packing process.

ROI: The SPD Team is looking at the overall reduction in expenditures to replace missing instruments to assess the value of this improvement.