The development and implementation of an AS/NZS 4187:2014 audit tool across regional Victoria

Mrs Lesley Lewis1

1Rural Infection Control Practice Group (RICPRAC), Wangaratta, Australia,

2Northeast Health Wangaratta, Wangaratta, Australia


The regular assessment of sterilizing services to ensure compliance with AS/NZS 4187 has been an established expectation of health services for many years.  Monitoring compliance with this standard is mandated 2.5.1 of AS/NZS 4187; and in criterion 3.16 of the National Safety and Quality Health Service Standards 2011.  The current version of the standard AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organizations was released in 2014 as a major Australian reference document guiding reusable medical device (RMD) reprocessing.


The Rural Infection Control Practice Group (RICPRAC) has designed and implemented an AS/NZS 4187:2014 audit tool.  The tool converts technical detail in AS/NZS 4187:2014 into108 criteria in a streamlined, efficient and effective audit process. The tool design evaluates the reprocessing matrix including governance elements and practice/ process elements.

RICPRAC coordinated its first audit using this tool across regional Victoria in 2016. Forty-five health service organizations voluntarily completed internal audits and submitted data to RICPRAC.


The audit found significant trends with multiple health service organizations recording noncompliance for the same criterion.

  • 30% of the HSO recorded the same noncompliance with 24% of the audit.
  • 50% of the HSO recorded the same noncompliance with 11% of the audit.

RICPRAC has now completed a second audit using this tool.


This presentation will discuss the audit tool development process. Its implementation and audit findings across a multi-centre audit project.  These will be compared with trends and changes found in the second audit one year later.


Lesley Lewis is a Regional Infection Control Consultant in Victoria and is a member of  RICPRAC

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