A steris service technician arrived onsite following the reported event to inspect the amsco 400 sterilizer.The technician inspected the unit and found the sterilizer to be operating according to specification.No issues with the function or operation of the unit were found.No repairs were required, and the unit was returned to service.The facility confirmed the biological indicator and chemical indicator in the cycle subject of the reported event evidenced passing results.During discussion with user facility personnel, the technician was informed that after the successfully completed cycle, an employee removed the load from the sterilizer and placed the instrument pack on a shelf located directly under an air conditioning vent.The root cause of the event can be attributed to user error.Facility personnel did not follow proper storage practices per the amsco 400 sterilizer operator manual, resulting in the reported moisture.The amsco 400 sterilizer operator manual (pg.6-4) states: "to prevent condensation, do not place load on a cold surface.Be sure that no air conditioning or cold air vents are in close proximity." the technician counseled the user facility on the proper use and operation of the sterilizer specifically, ensuring the customer is storing processed loads properly.No additional issues have been reported.
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The user facility reported that after a patient had been put under anesthesia, the pack containing the instruments to be used in the procedure was brought into the or.At that time, user facility personnel identified there to be moisture inside the pack.The patient was brought out of anesthesia and the procedure was postponed as the instruments had to be reprocessed; the facility had no additional instruments available for use.No report of injury.
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