A Case Study on Restarting SPD Water Systems the Wrong Way
When a boil water advisory is lifted, it’s easy to assume the crisis is over.
Water pressure is restored.
The notice is cleared.
Operations resume.
But under ANSI/AAMI ST108, the end of a boil water alert is not the end of risk—it’s the beginning of a required recovery process.
One hospital learned this lesson after restarting their system too quickly.
The Scenario: “The Alert Is Over—We’re Good to Go”
At a mid-size East Coast medical center, after a municipal water main break, the hospital operated under a boil water advisory for several days. During that time:
SPD operations were limited
Water usage was controlled
Facilities monitored incoming water conditions
When the advisory was officially lifted, Facilities did what they had always done:
Returned the system to normal operation
Allowed departments to resume water use
What they didn’t do was follow ST108 Section 13.2 recommissioning steps.
What ST108 13.2 Actually Requires After a Boil Water Alert
A boil water advisory requires formal verification, sanitization, and documentation before a critical water system is placed back into service. Lifting the advisory does not mean the water is immediately safe for medical device reprocessing. ST108 requires facilities to address three specific actions:
1. Verification: Don’t Assume the Water Is Acceptable
Municipal authorities lift boil water alerts based on public safety thresholds—not SPD requirements. ST108 expects Facilities to:
Verify water quality before resuming use
Confirm the system meets internal acceptance criteria
Ensure conditions are suitable for critical applications
In the case of this medical center, verification never occurred.
The assumption was: “If the city cleared it, it must be fine.”
2. Sanitization: Restarting Isn’t the Same as Recovery
Boil water alerts often involve:
Pressure loss
Flow disruption
Changes in microbial conditions
ST108 13.2 emphasizes that sanitization may be required before the system is returned to service. This particular medical center restarted without sanitizing. The system came back online—but whatever entered the system during the advisory came back online with it.
3. Documentation: If It’s Not Recorded, It Didn’t Happen
Recommissioning is not just a technical step—it’s a documented process.
ST108 requires Facilities to:
Record verification activities
Document sanitization steps
Maintain evidence of compliance
When SPD later asked what was done post-alert, Facilities had no records to provide.
The Consequence: SPD Felt the Impact First
Day 1:
Washer performance became inconsistent
Chemical indicators showed unexpected results
SPD raised concerns about water reliability
Testing revealed water quality that did not meet internal expectations, even though the boil alert had ended the day before. The issue wasn’t the alert itself. It was the lack of a formal recommissioning process afterward.
The Lesson Wendy Schultz Was Teaching
While sharing her observations about this situation during a recent webinar, Wendy noted that it wasn’t about emergency response. It was all about what happens next.
ST108 Section 13.2 exists because:
Boil water alerts disrupt system stability
Recovery requires intentional steps
“Turning the water back on” is not compliance
Facilities owns this process—but SPD bears the consequences when it’s skipped.
Key Takeaway for Facilities & SPD Leaders
If your facility experiences a boil water advisory, the end of the alert is not the finish line. Verification, sanitization, and documentation are required. ST108 expects a controlled, provable restart. The most common failure isn’t ignoring the alert. It’s assuming everything is fine once it’s lifted.
Final Thought
Boil water advisories are visible emergencies.
Improper recovery is an invisible risk.
ST108 13.2 exists to make sure the danger doesn’t linger after the notice is gone.