This a system for identifying risks in reprocessing medical devices and analysing the underlying causes. It is used to develop a profile of the risks inherent in the process for reprocessing reusable medical devices. Using this practice, information on reprocessing is also disseminated throughout the organization, primarily to the risk manager and management. Each adverse event is identified either by the clinicians who notice errors in their trays during use or by computer searches in the organization’s tracking software. These events are recorded in a database, Access, and the underlying causes are analysed to develop and implement measures to prevent recurrence.

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