Integrating ergonomic tools to reduce injury and strain in the packaging and assembly area

Improve productivity, reduce staff injuries, and enhance patient safety with a few simple tools

Medical devices or instruments go through numerous reprocessing steps before they’re deemed sterilized. The packaging and assembly area of the sterile processing department (SPD) is critical in assuring “the sterility of an item” while protecting “the contents until use.” To assure sterility, personnel must follow standards and guidelines to make sure the packaged instrument will not pose risks to patients.

 

The rigorous requirements for preparation for sterilization in ANSI/AAMI ST79:2017 requires that “devices should be cleaned; dried; inspected for cleanliness, flaws, and damage; assembled; and packaged according to the manufacturer’s written IFU.”1  To do so, ANSI/AAMI ST79 states that “there should be sufficient space for clean textile storage (both before and after assembly into packs), an illuminated inspection table, and patching equipment. …the clean work area should include space for magnifying lights; processing tables, which should be made of nonporous materials (e.g., stainless steel), ergonomic, and, preferably, height-adjustable.”

 

The effects of packaging and assembly on the musculoskeletal system

The packaging and assembly process during medical device reprocessing is often very labor-intensive and can lead to musculoskeletal disorders (MSDs). Many times, departments have the best intentions when designing and establishing a packaging and assembly area, only to realize a few more options would have helped improve ergonomics and overall employee satisfaction.

 

Meet ergonomic compliance

ANSI/AAMI ST79 and OSHA ergonomic guidelines2 require height-adjustable workstations. Sterile processing trays are often extremely heavy. Bending and lifting trays onto workstations that are not at comfortable working levels can lead to musculoskeletal disorders. According to OSHA, MSDs “affect the muscles, nerves, blood vessels, ligaments and tendons. Workers in many different industries and occupations can be exposed to risk factors at work, such as lifting heavy items, bending, reaching overhead, pushing and pulling heavy loads, working in awkward body postures and performing the same or similar tasks repetitively. Exposure to these known risk factors for MSDs increases a worker’s risk of injury.”

 

The repetitive motion tasks that are also associated with packaging and assembly can lead to injury and strain. Did you know that ergonomic options go beyond making workstations height-adjustable?

 

Reduce injuries from repetitive tasks

Keeping items easily within reach is key to reducing musculoskeletal disorders from repeated reaching. By employing an integrated pegboard wall, shelving, bins, peel pouch rolls and trays, tape dispensers and more can be designed with the user in mind. Pegboards allow items to be easily moved and adjusted to meet the end users physiological and workflow needs.

 

When it comes to workflow, “providing adequate space for supplies and equipment and designing the layout to facilitate the flow of work through the various steps of preparation contributes to the efficiency and accuracy of the sterile processing staff.”3

 

Meet lighting compliance

In 2013, researchers found that by integrating a few simple ergonomic changes into a department’s design can help improve staff safety. In one department, “a lack of space in the packing area,” led to “…undesirable twists when moving around equipment.”4 By leaving “enough space to establish safe and sound work processes,” the department’s workflow improved.

 

Another area in which prep and pack table design can benefit the end user is integrated lighting. ANSI/AAMI ST79: 2017, 3.3.5.6 states that “adequate lighting of work surfaces should be provided in accordance with the recommendations of the Illuminating Engineering Society of America (IES) for minimum levels of illumination…” The rationale is based on the “importance of speed or accuracy of the work done in the area (the greater the importance of speed or accuracy, the more illuminance needed).”

 

Upon completion of the cleaning process, staff must perform cleaning verification. “Cleaning verification by users should include (a) visual inspection combined with other verification methods that allow the assessment of both external surfaces and the inner housing and channels of medical devices…”

 

Many instruments have very small pieces and tips that look quite similar to the naked eye. It is even more difficult to notice these subtle differences under inadequate lighting. A 2019 study regarding errors in packaging surgical instruments found that “personnel error is the primary reason for packaging errors. Central sterile supply department (CSSD) staff members are not familiar with the clinical utilization of surgical instruments, and therefore it was hard for them to distinguish between instruments with minor differences.”5

 

To avoid errors in packaging surgical instruments, departments can meet compliance with magnifying task lighting. Magnifying task lights improve patient safety by enhancing visual inspection with direct light, as well as allowing technicians to verify cleaning processes and assess any damage to instruments prior to sterilization. Of equal importance, magnification and lighting improve staff safety by reducing eye and neck strain.

 

Find sterile wrap perforations without eye strain

Additionally, when wrapping trays with woven and nonwoven sterile wraps, ANSI/AAMI ST79:2017, 9.5 states that departments must “inspect the wrap to ensure that it is free of defects that could have an adverse effect on the performance of the material.”

 

The International Association of Healthcare Central Service Materiel Management (IAHCSMM) recommends that visual “inspection is performed using a light table that has a light source built into the tabletop to help spot small holes and punctures. As the wrap is passed over the lighted table top, light shines through the small holes and punctures making them easier to identify.”6 By doing so, imperfections and perforations in sterile wrap materials can easily be identified and staff do not have to strain to find small holes.

 

Reduce medical costs while increasing productivity and patient and staff safety

In 2008, researchers sought to connect the costs of injuries and strains on a sterile processing department and in turn, design an intervention to alleviate the number of injuries and straining. The study found that in this particular department, “between 2001 and mid-year 2005, employees in the sterile processing center (SPC) experienced 32 injuries, costing $187,266.00 in direct medical costs (i.e., loss expenses), with strain injuries accounting for 94% of the total expenses and 50% of the total injuries.”7 Many departments are already backlogged with cases and need capacity boosting solutions. Adding injuries and strain to staff only creates further backlogs. By integrating ergonomic solutions in the packaging and assembly area, costs are reduced and throughput is increased. Not to mention, staff productivity and employee satisfaction are boosted as well.

 

Learn more about Pure Processing height-adjustable workstations and inspection tables to meet your workflow and workplace environment goals.

Want to earn 1 free CE? Watch Under Wraps: Packaging Materials, Their History, Efficacy and Creating Packaging Material Inspection Protocols

 

References

 

  1. Association For The Advancement Of Medical Instrumentation. Sterilization Standards Committee, Association For The Advancement Of Medical Instrumentation, & American National Standards Institute. (2017). Comprehensive guide to steam sterilization and sterility assurance in health care facilities. Arlington, Va: Association For The Advancement Of Medical Instrumentation.
  2. Ergonomics – Overview | Occupational Safety and Health Administration. (n.d.). Retrieved February 3, 2021, from www.osha.gov website: https://www.osha.gov/ergonomics
  3. Association For The Advancement Of Medical Instrumentation. Sterilization Standards Committee, Association For The Advancement Of Medical Instrumentation, & American National Standards Institute. (2017). Comprehensive guide to steam sterilization and sterility assurance in health care facilities. Arlington, Va: Association For The Advancement Of Medical Instrumentation.
  4. Hall-Andersen, L. B., & Broberg, O. (2014). Integrating ergonomics into engineering design: The role of objects. Applied Ergonomics, 45(3), 647–654. https://doi.org/10.1016/j.apergo.2013.09.002
  5. Zhu, X., Yuan, L., Li, T., & Cheng, P. (2019). Errors in packaging surgical instruments based on a surgical instrument tracking system: an observational study. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4007-3
  6. International Association Of Healthcare Central Service Material Management. (2016). Central Service Technical Manual. (p. ). : IAHCSMM.
  7. Boynton, T., & Darragh, A. R. (2008). Participatory ergonomics intervention in a sterile processing center: a case study. Work (Reading, Mass.), 31(1), 95–99. Retrieved from https://pubmed.ncbi.nlm.nih.gov/18820424/

 

 

 

 

 

 

 

 

 

 

 

 

 

5 ways healthcare reprocessing sinks improve workflow and productivity

How healthcare reprocessing sinks are a better option than commercial stainless steel sinks

In central sterile processing departments, the decontamination area’s reprocessing sinks represent the most critical area in ensuring that instruments are being properly cleaned. While commercial stainless steel sinks are commonly used for reprocessing medical instruments, not all sinks are created equally.

Manual cleaning and disinfection of instruments requires that sinks have either two- or three-basin sections1 to soak, rinse and provide a final rinse with critical water. The American National Standards Institute (ANSI) and Association for the Advancement of Medical Instrument (AAMI) standard ST79:2017 also recommends that sinks have “attached solid counters or adjacent work surfaces on which to place soiled and clean items separately.”

To make the most of the space available in the limited confines of the decontamination area, sinks need to also serve as a workstation. Unlike commercial stainless steel sinks, healthcare reprocessing sinks are designed with the decontamination tasks and users in mind. As such, ergonomics and workflow standards and recommendations are met.

 

5 ways healthcare reprocessing sinks improve productivity and quality

  1. Ergonomics
    Height-adjustable healthcare reprocessing sinks meet Occupational Safety and Health Act (OSHA)2 compliance and reduce musculoskeletal disorders. Central sterile processing personnel heights and physical capabilities vary, making height adjustability a necessity to perform duties optimally. Height-adjustability also comes in varying options. While the overall sink can be height-adjustable, having an attached pegboard or shelf under the sink that moves with the sink, also helps alleviate staff pain from bending and reaching by keeping tools within easy reach.
  2. Protection from aerosolization
    While personal protective equipment (PPE) is a necessity, sinks can also provide another way to ensure the reduction of aerosolization. Aerosols can make contact with personnel from any direction and can transfer microorganisms to personnel. The incorporation of a sink basin splash guard allows for personnel to be able to manually clean instruments without being exposed to dangerous organisms.
  3. Workflow
    Incorporating tools that ensure proper workflow allows healthcare reprocessing sinks to become a training tool. Workflow plates that indicate whether a particular basin is to be used for soaking, rinsing, or a final critical water rinse can be used as a training tool to educate new hires. It also serves as a reminder to veteran personnel when redundant, repetitive tasks can lead to overlook protocols. Workflow plates are also removable for easy cleaning.
  4. Lighting
    ANSI/AAMIST:79 requires adequate lighting of work surfaces.” Ancillary lighting should be considered for areas where instruments are manually cleaned and inspected.” Task lights with magnifying lenses allow personnel to be able to visually verify the cleaning process. Magnifying task lights can be installed on a pegboard with an adjustable arm that meets the ergonomic needs of each staff member for less eye strain and greater inspection capabilities.
  5. Instrument protection
    Tools such as staging panels and sink liners protect the tips of delicate, expensive instruments when more space is needed. By adding a staging panel to an existing sink basin, the sink’s built in counter space is expanded to help stage instruments prior to sterilization. Sink liners in basins and on sink countertops provide a soft-landing area to prevent damage to instruments while they are staged.

 

 

Learn more about Pure Processing healthcare reprocessing sinks, which feature moveable pegboard and shelving accessories to meet your workflow and workplace environment goals.

Looking for more sterile processing articles? Read Central Sterile Processing Education and Training Are Key to Reducing HAIs.

 

References:

  1. United States Department of Labor. Central supply. Occupational Safety and Health Administration.. https://www.osha.gov/SLTC/etools/hospital/central/central.html
  2. Association for the Advancement of Medical Instrumentation (2017). ANSI/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in healthcare facilities.

 

 

 

 

 

Eliminate the Negative Decontamination Stigma

Learn to Love the Decontamination Area of Your Sterile Processing Department

When it comes to medical device reprocessing, the most critical tasks happen in the decontamination area of sterile processing departments. Proper pre-cleaning is the foundational step to patient care. So why do negative stigmas surrounding the decontamination area of sterile processing departments continue to be an issue?

3 Issues that Cause Poor Stigma Regarding Decontamination

  1. Space and equipment issues
    Sterile processing departments are not always outfitted with the right equipment or infrastructure needed to perform the responsibilities that have been assigned. Sterile processing departments may need a three-bay sink and will often have two bays in which to work. As a result, the responsibility falls to the technician to make the equipment achieve both compliance and performance. In departments where space is limited, this becomes a bigger challenge. Poor equipment and departmental limitations can immediately cause the decontamination area to become a place of frustration.
  2. Pain and discomfort
    The decontamination area is a dangerous place to work. Ergonomic hazards to technicians are ripe with injuries from sharps and the body becomes physically tasked when repeatedly lifting trays and bending over sink basins cleaning instruments. Additionally, the decontamination area is hot and sweaty. Add the layers of personal protective equipment (PPE) equipment required to work in the decontamination area and it becomes even more hot and sweaty. Over time, the conditions can put a physical strain on technicians and put them at risk for injury. As a result, it becomes hard to enjoy working in an area that causes pain and discomfort.
  3. Utilizing decontamination as a punishment
    Scheduling can become a major root of poor stigmas in the decontamination area. Managers tend to continue to schedule the same people to work in the decontamination area. Consequently, the long shifts are staffed by the same technicians. Departments that implement frequent rotations of personnel may see improvements in negative attitudes. Additionally, due to the negative perception of working in decontamination, managers will also threaten to punish employees by sending them to work in decontamination. When technicians are overworked and underappreciated in the decontamination area, employee dissatisfaction becomes an issue.

Removing the negative stigma surrounding working in the decontamination area

Removing the stigmas surrounding working in the decontamination area begin with the central sterile processing department leadership. Technicians need to understand and believe that there is no task that is too small when it comes to performing the important work in decontamination. Every channel, every instrument set, every tip is a valuable tool in delivering safe patient outcomes. Technicians, managers, and supervisors are the gatekeepers of patient and staff safety and are responsible for ensuring that each item that comes through the sterile processing department is clean. Remember, every member of the team is vitally important in this process.

Recognizing the demanding work that staff perform in the decontamination area is another step toward eliminating the negative stigmas. When technicians take time and perform their duties meticulously and end their shift with all case carts completed, managers and supervisors should recognize those achievements. Sterile processing professionals can never hear “thank you,” or “good job,” enough.

Sterile processing departments should not underestimate that the element of fear could also be the result of negative perceptions when it comes to working decontamination. If you have never worked in sterile processing, and a technician’s first introduction to the sterile processing department begins in decontamination, the area can seem intimidating. Manufacturer instructions for use (IFU) are quite rigorous with no wiggle room for mistakes. For example, technicians must follow the IFU or suffer the risk to patient and staff safety. Decontamination is a dangerous environment, and proper training for technicians to feel comfortable working in decontamination necessary for successful patient outcomes.

3 tools to help shift negative sterile processing department decontamination perceptions to generate positive results

  1. Identify sterile processing vendors that are actively involved in producing tools for the decontamination space.
    Vendors may provide equipment for decontamination, but if they are not actively engaged in improving that space, they cannot be a long-term partner for addressing the issues you find in decontamination.If departments do not have enough funds allocated in the budget for new sinks, consider sink inserts, which can raise the working level and make your deep sink basins much more manageable. Departments can also consider ergonomic improvements such as anti-fatigue mats. These small tweaks make a difference for the working conditions in decontamination and lead to better staff engagement and satisfaction.
  2. Mobilize and empower sterile processing teams by sharing the responsibility of auditing and improving the decontamination department processes.
    Personnel can help guide departments to implement the best, long-term fixes for their department. By seeking staff input, department leaders can create a collaborative environment in which to celebrate working in decontamination. Department leaders who consistently communicate and educate regarding the importance of decontamination, immediately create a more welcoming atmosphere. Education is a critical pillar to building a solid decontamination area. Sterile processing departments can experience great benefits from partnering with local IAHCSMM chapters and exchanging ideas and information. When departments sponsor decontamination-related education, it sends a signal that the decontamination area is important.
  3. Find a decontam champion!
    In sterile processing departments where negative resentments around decontamination persist, your champion, when mobilized, will help others learn to love decontamination. Involving the decontamination champion can help departments when evaluating new product improvements. Decontam champions can also create great partnerships with educators when performing decontamination in-service training. If staff see decontamination as a dead-end, it will begin to affect the entire team. However, if departments can provide routes to improve staff mentalities with a champion program, sterile processing department leadership demonstrates that personnel talents, knowledge, skills, and abilities are recognized. A champion can be a powerful thing.

Stigmas surrounding the decontamination area can always end with sterile processing leadership personnel. If you love decontamination, then your team will learn to love it as well. You can never overcommunicate the significance that decontamination holds in the sterile processing department.

For a more in-depth discussion regarding the negative stigmas surrounding the decontamination areas of sterile processing and to earn .05 CE credits, listen to IAHCSMM’s Process This podcast. Pure Processing’s business operations manager, Megan Pietura, addresses more solutions creating a positive atmosphere in the decontamination department.

 

 

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3 Ways Height Adjustable Sinks and Tables Improve Sterile Processing Workflow

According to the Occupational Safety and Health Administration (OSHA), “Ergonomics is the practice of designing equipment and work tasks to conform to the capability of the worker.” The ultimate purpose of this practice is to prevent injuries to staff while they are performing their tasks.

Preventable injuries create a host of negative consequences to workers and their employers, including:

  • Pain and an inability to perform tasks
  • Healthcare and worker’s compensation costs
  • Temporary staffing costs
  • Possible turnover and retraining costs
  • Lost productivity and morale
  • Lost revenue

OSHA’s Occupational Safety and Health Act of 1970 mandates that employers provide workplaces that are “free from recognized hazards that are causing or are likely to cause death or serious physical harm” to employees.

 

Sterile processing worker and workflow hazards

OSHA says hospitals are among the most hazardous places to work. During the 12 months of 2014, the Bureau of Labor Statistics recorded 294,000 nonfatal work-related illnesses and injuries in U.S. hospitals.

Ergonomic hazards in sterile processing departments (SPDs) are typically musculoskeletal disorders (MSD) associated with bending, reaching and repetitive motion tasks. Specifically, when working in sinks, technicians must sort, take apart, and manually pre-clean each device or instrument, and then prepare it for disinfection or sterilization processes.

These tasks are performed hundreds of times a week, and have typically been done while standing at static, deep sinks designed for the restaurant industry. Workers spend hours on their feet each day inspecting instruments and trays and wrapping each tray for sterilization. These tasks are often performed at a non-adjustable workstation that is not designed with staff safety in mind.

 

Focus on sterile processing ergonomics

Whether they are performed in the GI department or the sterile processing department, reprocessing tasks are rife with potentially uncomfortable activities. These range from prolonged standing in one place, to awkward postures and repeated extreme bending, or performing repetitive wrist and arm movements that can cause pain and numbness. Some ergonomic solutions were designed to be added to existing department equipment. However, when a department is ready to remodel, or a new facility is being built, an opportunity is created to identify ergonomic hazards and address them more thoroughly through better designed pre-cleaning workflows and permanently installed injury-prevention solutions.

OSHA has provided specific “possible solutions” to help address ergonomic injuries in the SPD (also known as Central Supply). They are intended to be applied to other similar work areas in the hospital. Among other suggestions, they include:

  • Redesign workstations so packaging and equipment can be reached while maintaining elbows close to the body
  • Use height-adjustable work surfaces
  • Minimize prolonged overhead activity (to avoid reaching over shoulder height)

In addition, the American National Standards Institute (ANSI) and the Association for the Advancement of Medical Instrumentation (AAMI) issued a joint document, the ANSI/AAMI ST79: 2017, 3.3.6.1.3,  which offers more detailed recommendations for setting up a decontamination area:  “Ergonomic factors affecting worker safety and comfort should be considered when designing work spaces in the decontamination area, including: a) adjustable counters, sinks, and work surfaces positioned at heights that take into account the average height of the employees and the tasks to be performed at each location.”

The standard also states:

“Designing the area to facilitate efficient work flow and to provide adequate space for necessary equipment can reduce the potential for cross-contamination and enhance efficiency. Considering ergonomic factors during the design phase can help prevent worker injury.”

 

All utility sinks are not healthcare reprocessing sinks!

Every effort should be made to make the sink area station as ergonomic as possible since it is the primary pre-cleaning work site. In the past, healthcare facilities had few options for sinks that could be used to reprocess devices. Their stainless steel sinks, not designed for healthcare functions, were unnecessarily deep. When used for healthcare instrument reprocessing activities, they have been a source of MSD of the hip, back, shoulder, and arm.

 

All prep and pack tables are not equal

Workstations in the assembly area of sterile processing are one of the most critical pieces of equipment required to properly inspect and package instruments prior to sterilization. Workstations without ergonomic considerations are a culprit in back, hip, shoulder, arm, and eye strain.

Incorporating a height-adjustable countertop as well as an attached pegboard allows users to raise or lower the workstation to meet their height while also allowing supplies and tools to be within easy reach. Attached task lights also move with the height-adjustability of the workstation, aiding in reducing eye and neck strain during inspection tasks.

Healthcare manufacturers identified the need to supply more ergonomic equipment and are developing better tools for these critical functions.

 

Workflow is essential to productivity

It is important to understand the flow of tasks and activities, the challenges and bottlenecks, the specific items being processed, and which specific processes are being used. In addition, the workflow requirements of all reprocessing stakeholders must be considered: Technicians, facility management, and the infection control department. Everyone should express their objectives and challenges in order to design the best solution for all. Planning for inventory growth and turnover is also a consideration for this area.

 

Three ways height-adjustable sinks and workstations improve workflow

1.  Height-adjustable sinks and workstation allow for less strain and minimize overhead activity

A height-adjustable sink or workstation allows fully customizable placement of the tools for individual technicians and brings items closer to the user. A height-adjustable pegboard and other movable hanging storage systems bring tools to users’ fingertips. Height adjustment on sinks and workstations enable the optimal ergonomic working height setting and head tilt for virtually any user, to help avoid strain and injury.

2.  Ability to rotate workers through repetitive tasks

The ability to instantly customize the height and reach of a sink or workstation electronically with the push of a button, makes it fast and easy to rotate staff members with different ergonomic needs and capabilities at the sink and workstation.

3.  Reducing the Clutter Factor

There is a strong indirect correlation between clutter and productivity in any workplace. Cluttered workstations add to workers’ time and effort, add to personal stress and morale, and can eventually affect the quality of work. In healthcare reprocessing areas, poor job quality can have a much more serious consequence: It can affect worker and patient health and safety.

Reprocessing areas are typically complex environments, with numerous cleaning tools, instructions, jugs of chemistries, device parts, packaging and assembly supplies in and around the work areas. Clutter and disorganization are very common conditions in these work areas because of the inherent nature of the work. A messy workspace requires more reaching, untangling and other musculoskeletal activity, which adds to the ergonomic stressors already in play. Additionally, heavily cluttered areas also carry the risk of becoming a breeding ground for organisms that can contaminate surfaces, tools and devices.

 

Improve your sterile processing workflow with the right tools

Before selecting a sink or workstation intended to be used as a medical device reprocessing tool, hospital decision-makers must consider this: Are they using a local fabricator or supplier with general sink design experience, or consulting a healthcare specialty manufacturer with extensive research and observation-based knowledge of the reprocessing function and its related requirements?

OSHA has made it clear that attention to proper ergonomics helps reduce injuries and discomfort that can affect a worker’s ability to function, and that identifying and addressing ergonomic issues should be a mandatory practice for all industries. Providing an ergonomic workplace can also help employers reduce healthcare and other costs related to avoidable injuries, so it is in their best interest to do so.

By installing and using a powered, auto-height adjustable healthcare reprocessing sink or prep and pack workstation, and providing ergonomic storage to organize the immediate workspace, sterile processing management can eliminate unnecessary pain and costs while developing a safe, efficient and highly productive workflow to better support clinical areas of their hospital. These industry-specific tools provide a simple and valuable solution for healthcare providers.

 

Learn more about Pure Processing height-adjustable tables and sinks, which feature moveable pegboard and shelving accessories to meet your workflow and workplace environment goals.

Looking for more sterile processing articles? Read Central Sterile Processing Education and Training Are Key to Reducing HAIs

 

References

  1. U.S. Bureau of Labor Statistics (2016). Hospital workers suffered 294,000 nonfatal workplace injuries and illnesses in 2014. TED: The Economics Daily. Accessed online 10/27/20. https://www.bls.gov/opub/ted/2016/hospital-workers-suffered-294000-nonfatal-workplace-injuries-and-illnesses-in-2014.htm
  2. United States Department of Labor. Healthcare wide hazards. Occupational Health and Safety Administration. Accessed online 10/26/20. https://www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.html
  3. The Joint Commission (2014). OSHA worker safety in hospitals program launched online. Environment of Care News, April 2014, Volume 17, Issue 4. Accessed online 10/27/20. http://www.jcrinc.com/assets/1/7/EC-News-Apr-2014-1.pdf
  4. Centers for Disease Control and Prevention. Healthcare workers. The National Institute for Occupational Safety and Health (NIOSH). Accessed online 10/26/20. http://www.cdc.gov/niosh/topics/healthcare/default.html
  5. United States Department of Labor. Central supply. Occupational Safety and Health Administration. Accessed online 10/26/20. https://www.osha.gov/SLTC/etools/hospital/central/central.html
  6. United States Department of Labor. Occupational Safety and Health Administration. Accessed online 10/26/20. https://www.oshatrain.org/courses/pdf/OSHAErgonomics.pdf
  7. Dawson, Lawrence (2008). 6 reasons to clean out the clutter. Industrial Safety and Hygiene News. Accessed online 10/26/20. http://www.ishn.com/articles/87360-6-reasons-to-clean-out-the-clutter
  8. Association for the Advancement of Medical Instrumentation (2017). ANSI/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in healthcare facilities. Accessed online 10/26/20.