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An implant was opened onto the sterile field and the inner wrapper was found to be unsterile.Being unsure of the packaging the nurse questioned the room staff if the inner packaging was sterile or not.The nurse was told it was.After handing the inner package to the scrub nurse the outer package was looked at again and a disclaimer was noticed saying that the inner packaging was not sterile.The scrub nurse was notified right away and it was handed off.The scrub nurse changed gloves and covered the backtable where it had been placed while being removed from its protective plastic tray.It never went up to the surgical site.The packaging should have a warning label placed closer to the area where the outer unsterile package is to be opened.Also a disclaimer on the inner unsterile packaging would be helpful in avoiding this from happening again.When one opens the box, there is a foil pouch, approximately 24" x 13", that is sealed around the four sides, with a peel away notch at one end.On one side, there is a label measuring 7.5 x4", which issues a warning: "this foil pouch and the outer surface of the inner pouch are non-sterile.The contents of the inner pouch are sterile.Use immediately one the pouch has been opened."
the reporter did not see the label in the heat of the moment, peeled the foil package open at the notch, and put the unsterile inner package onto the sterile field.They should have removed the inner package, opened it, and the contents of that package could have been placed on the field.
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