NAVGRAM LESSONS LEARNED F H F 1 JAN 91 TO 31 JAN 91

File: 102596_sep96_decls5_0009.txt
Page: 0009
Total Pages: 20

Subject: NAVGRAM LESSONS LEARNED F H F 1 JAN 91 TO 31 JAN 91             

Unit: FLEET HOSP  

Parent Organization: NAVCENTCOM  

Box ID: BX300052

Folder Title: FLEET HOSPITAL WORKING PAPERS VARIOUS SOURCES CNA 2837                                          

Document Number:         58

Folder SEQ  #:         11






                                            UNCLASSIFIED



               B. DISCUSSION: A COMBINATION OF FORCES COME INTO PLAY TO
          CAUSE PROBLEMS WITH THE INSTRUMENTATION AND SOME OF THE MAJOR
          CAUSES CREATE A "DOMINO EFFECT" IN THE PROCESS OF DEGRADATION
          WHICH EVENTUALLY RESULTS     IN A SHORTENED      INSTRUMENT LIFE.
          CONTRIBUTING FACTORS ARE:
               (1) UTILIZATION OF HARD WATER FOR THE DECONTAMINATION
          SOLUTION, CLEANING SOLUTION AND RINSING OF INSTRUMENT AS WELL AS
          IN THE STERILIZERS TO GENERATE STEAM.
               (2) THE USE DF MINIMUM GRADE SURGICAL STEEL OR SURGICAL
          STEEL AMALGAMS TO FABRICATE INSTRUMENTS RESULTS IN POOR QUALITY
          AND/OR CHROME PLATING IMPERFECTIONS WHICH ALLOWS FOR ELECTROLYSIS
          DURING THE STERILIZATION PROCESS. IT IS THE CHROME PLATING THAT
          GIVES PASSIVITY TO THE INSTRUMENTATION, WHICH IF PRESERVED
          THROUGH TAKING CARE OF THE INSTRUMENTS, WILL ENSURE A LONG,
          HEALTHY INSTRUMENT LIFE FREE OF SPOTTING, RUSTING, PITTING AND
          CORROSION. MINIMUM QUALITY INSTRUMENTS MAY HAVE HAIRLINE CRACKS
          AND/OR POOR CHROME FINISHES WHICH REDUCES THE ABILITY TO WARD OFF
          INSULT CAUSED BY NORMAL USE AND PROCESSING.
               (3) THE STERILIZER, SURGICAL, INSTRUMENT AND DRESSING (NSN
          6530-00-926-2151), COMMONLY REFERRED TO AS A FIELD STERILIZER,
          FOR THE MOST PART IS A RELIABLE UNIT WHEN USED IN THE SETTING AND
          CONDITIONS FOR WHICH IT IS INTENDED. THE AMOUNTS AND TYPES OF
          STERILIZATION NEEDED FOR A FACILITY OF THIS SIZE FAR EXCEEDS THE
          EQUIPMENT AND INSTRUMENTATION REQUIREMENTS AT THE RDMF OR BAS
          LEVEL. SOME OF THE PROBLEMS WITH THE FIELD STERILIZER INCLUDE:
                    (A) THE CHAMBER TRAP (PART NUMBER A300-224-1/98)
                    RAPIDLY BECOMES NONFUNCTIONAL (4 OUT OF 8 UNITS NEED
                    THE CHAMBER TRAP REPLACED).
AVAILABLE IMMEDIATELY;
                    ESPECIALLY RUBBER GASKETS SINCE UNITS THAT HAVE BEEN
                    PACKED FOR ANY LENGTH OF TIME MAY HAVE BEEN DAMAGED DUE
                    TO EXTREME CONDITIONS OF EXCESSIVE HEAT AND/OR COLD.
                    (C) A SOURCE OF DISTILLED WATER NEEDS TO BE
                    CONTINUOUSLY AVAILABLE FOR USE IN THE UNITS FOR THE
                    CLEANEST POSSIBLE STEAM GENERATION (I.E. DISTILLERY,
                    REFLUPS, REVERSE OSMOSIS UNITS ON THE CENTRAL STERILE
                    REPROCESSING WATER SUPPLY FAUCETS).
                    (D) STERILIZER CARE PRODUCTS SHOULD BE ON THE INITIAL
                    PLATFORM AND THEN BE CONTINUOUSLY AVAILABLE VIA THE
                    SUPPLY CHAIN FOR ROUTINE UNIT CLEANING MAINTENANCE,
                    SUCH AS TRI SODIUM PHOSPHATE (TSP) FOR WEEKLY, TO FLUSH
                    THE CHAMBER DRAIN AND ELIMINATE MINERAL DEPOSITS;
                    WHITE VINEGAR TO DAILY WIPE OUT THE INNER CHAMBER AND
                    DECREASE MINERAL DEPOSIT BUILD UP; SILICONE LUBRICANT
                    TO KEEP RUBBER GASKETS FROM PREMATURE HEAT DEGRADATION.
                    (E) A PREVENTIVE MAINTENANCE PROGRAM SHOULD BE
                    IMMEDIATELY INSTITUTED BY BIOMEDICAL REPAIR, SO THAT
                    PROBLEMS CAN BE AVOIDED, DELAYED, OR ANTICIPATED. THIS
                    WOULD DECREASE DOWN TIME DUE TO REPAIRS AND MINIMIZE
                    IMPACT UPON THE DEPARTMENTS STERILIZATION MISSION.




                                        UNCLASSIFIED

Document 20 f:/Week-36/BX300052/FLEET HOSPITAL WORKING PAPERS VARIOUS SOURCES CNA 2837/navgram lessons learned f h f 1 jan 91 to 31 jan:1018961451347
Control Fields 17
File Room = sep96_declassified
File Cabinet = Week-36
Box ID = BX300052
Unit = FLEET HOSP
Parent Organization = NAVCENTCOM
Folder Title = FLEET HOSPITAL WORKING PAPERS VARIOUS SOURCES CNA 2837
Folder Seq # = 11
Subject = NAVGRAM LESSONS LEARNED F H F 1 JAN 91 TO 31 JAN
Document Seq # = 58
Document Date =
Scan Date =
Queued for Declassification = 01-JAN-1980
Short Term Referral = 01-JAN-1980
Long Term Referral = 01-JAN-1980
Permanent Referral = 01-JAN-1980
Non-Health Related Document = 01-JAN-1980
Declassified = 18-OCT-1996