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INSTRUMENT READINESS

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Department<br />

Veteran<br />

Affairs-2007<br />

SPD-OR<br />

Coordination<br />

Study<br />

25% facilities-instrument trays<br />

or surgical case carts had<br />

instruments broken, incorrect,<br />

missing<br />

Occasionally receiving unsterile<br />

instruments<br />

Broken process in the flow from<br />

the SPD to the ORS<br />

Cause-unknowledgeable staff

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