Stress-test an instrument tray shortage by proving that each hold window and restore rule can place unanswered tray requests inside the planned lane, survive override pressure, and avoid trapping OR teams inside a green tray slide that hides long-lived soft holds.
Instrument tray shortages often list a loaner plan while leaving restore behavior, override authority, and abort ownership implicit. Those edges decide whether a late hold stays inside the tray packet or leaves a broken tray path live under peak volume. The exercise should follow actual tray inventories, room maps, and escalation paths rather than a clean sterile deck.
Inventory before the drill
List every tray class with its response window, waive rule, override behavior, owners, and notification channels. Mark paths that cannot reverse without a manual amendment. Attach the last three instrument tray shortage incidents with raw timelines and any waivers. Include the source of truth for open tray counts during the observation window.
Define the phases for detect, hold, divert, abort, and restore. Each phase needs an owner and an exit condition. Write the point after which a stuck hold would require a different procedure, then review whether that action is still permitted. Capture maximum acceptable dwell in measurable units, including which service lines are excluded from the shortage path and why.
Include the calendar of known events for the next two quarters: block freezes, vendor delays, and sterilizer downtime that shrink the usable response window. A tray budget that ignores those dates will look calm until the week they land.
Shortage scenarios worth timing
- A minority specialty tray keeps a side-channel while the aggregate tray dashboard stays green.
- A restore has already left a room without a trusted tray state.
- The primary tray dashboard lags beyond the planned observation window.
- An operator skips a tray gate because a case cutoff is near.
- Automated and human divert messages collide under the new shortage rule.
- Abort authority is unclear at week end and the update lands on the wrong amendment.
For each scenario, identify detection time, room impact, containment, and the authority to force an instrument tray rollback. Require commands and dashboard links in the runbook.
Ownership once the shortage window closes
Run the package in Pingpong with sterile processing, perioperative, OR ops, and materials seats. Ask sterile processing which tray decision becomes unsafe first if holds still stick after the claimed window. Ask OR ops whether room macros can absorb a forced override. Ask owners to show the exact tray version or export used as the exit condition.
Related reviews include a sterile processing rewrite, the perioperative lead seat, a preop clearance ladder, and the OR ops lead seat. Browse the war-game decisions hub for adjacent controls.
Authorize the published tray path only after a timed drill restores usable hold hygiene inside the documented budget without an undocumented manual step.