TY - JOUR T1 - Unravelling the magic of latent safety threats JF - BMJ Quality & Safety JO - BMJ Qual Saf SP - 265 LP - 267 DO - 10.1136/bmjqs-2020-012149 VL - 30 IS - 4 AU - Yadin David Y1 - 2021/04/01 UR - http://qualitysafety.bmj.com/content/30/4/265.abstract N2 - Sterile processing errors in medical and dental offices are ranked the third highest hazard according to the annual ECRI ‘Top 10 Health Technology Hazards’ 2020 report.1 Other experts have raised similar concerns with sterilisation processes. For example, the WHO and the Clinical Engineering Division of International Federation of Medical and Biological Engineering (IFMBE) have partnered to provide a series of webinars with international experts exchanging knowledge on COVID-19 related critical topics. A recent webinar addressed the critical challenge of decontamination and disinfection of COVID-19 medical equipment in low-income and middle-income countries.2 During the webinar, participants asked about methodologies to assess whether the transmission of infection is borne by technological tools used to fight the disease. How can critical lifesaving breathing equipment be safely and quickly sterilised and moved from one patient to the next? The WHO/IFMBE webinar2 stated that ‘engineers and infection control professionals seem to be working in different silos’. Such silos must be dismantled because medical technology is indispensable in the provisioning of healthcare services. Disinfection and sterilisation of medical equipment are key concerns for healthcare organisations, and they require serious consideration of sociotechnical system interactions. The annual ‘top 10 Health Technology Hazards report’ is based on retrospective studies, yet management of COVID-19 safety requires capacity to process real-time data and the input of experts to predict where risks may occur and how to deploy plans to maintain a safe healthcare environment.Alfred et al 3 in this issue of BMJ Quality & Safety describe the Sterile Processing Department (SPD) as ‘an example of a socio-technical system, where people, procedure, technology, environment, and organization interact to produce a range of proximal and distal outcomes’.3 The goal of their study was to ‘develop a comprehensive understanding of the SPD assembly work system by uncovering key … ER -