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Criterion Links: 16.2.1
PI-16-001
Sterilisation & CSSD
alert Zone
Central Sterile Supply Department (CSSD) Autoclave Biological Indicator Pass Rate
Biological indicator validation confirms spore lethality and sterility assurance of surgical instruments.
Target Threshold100%
Latest Result99.1%
SIQ Trigger Condition Met
PI-16-001Critical breach zone for 2 or more consecutive periods
Consecutive periods in breach zone: Dec 2024 (98.8%) and Jan 2025 (98.8%).
PI-16-001
18 recorded periodsEntered (filled)
Imported (hollow)
Breach point (enlarged)
Target Breach threshold Adoption date (8 Dec 2025)
Indicator Tracking Register & Readings
Historical numerator and denominator logs. Results are derived mathematically on every render.
| Period | Numerator | Denominator | Result | Target | Zone | Action Taken | Source |
|---|---|---|---|---|---|---|---|
| Oct 2024 | 79 | 80 | 98.8 | 100% | breach | — | imported |
| Nov 2024 | 96 | 97 | 99 | 100% | alert | — | imported |
| Dec 2024 | 81 | 82 | 98.8 | 100% | breach | — | imported |
| Jan 2025 | 83 | 84 | 98.8 | 100% | breach | — | imported |
| Feb 2025 | 113 | 114 | 99.1 | 100% | alert | — | imported |
| Mar 2025 | 99 | 100 | 99 | 100% | alert | — | imported |
| Apr 2025 | 109 | 110 | 99.1 | 100% | alert | — | imported |
| May 2025 | 95 | 96 | 99 | 100% | alert | — | imported |
| Jun 2025 | 110 | 111 | 99.1 | 100% | alert | — | imported |
| Jul 2025 | 91 | 92 | 98.9 | 100% | breach | — | imported |
| Aug 2025 | 112 | 113 | 99.1 | 100% | alert | — | imported |
| Sep 2025 | 93 | 94 | 98.9 | 100% | breach | — | imported |
| Oct 2025 | 98 | 99 | 99 | 100% | alert | — | imported |
| Nov 2025 | 112 | 113 | 99.1 | 100% | alert | — | imported |
| Dec 2025 | 80 | 81 | 98.8 | 100% | breach | — | imported |
| Jan 2026 | 95 | 96 | 99 | 100% | alert | — | entered |
| Feb 2026 | 108 | 109 | 99.1 | 100% | alert | — | entered |
| Mar 2026 | 113 | 114 | 99.1 | 100% | alert | — | entered |