The Cost of a Sterilization Failure: Jake Gleeson’s Story
Updated: Sep 22
One plate. Fourteen surgeries. A career over.
Jake Gleeson at HSPA 2026
In 2018, a routine elective procedure became a life-altering sterilization failure for Jake Gleeson, a former Portland Timbers goalkeeper, MLS Cup champion and Olympian. The case ended with a jury verdict exceeding $20 million—and a warning for every sterile processing, surgical services and executive team.
Could the same failure happen in your facility?
Jake Gleeson as a young goalkeeper
What happened
An elective procedure—and a missing implant
On August 15, 2018, Gleeson underwent bilateral internal fixation with plates and screws, along with bone marrow harvesting, at an outpatient surgery center in Portland. While he was under anesthesia, the plate ordered for his right shinbone could not be found.
A replacement plate was brought in from another surgical center and processed immediately. The surgery was elective—not an emergency.
Minutes instead of hours
According to testimony reported in the case, the replacement plate received immediate-use steam sterilization (IUSS), historically called “flash sterilization,” for approximately 15–20 minutes. A standard full processing cycle would have taken several hours.
IUSS has a limited role in true emergencies. CDC guidance and ANSI/AAMI ST79 caution against using it for implantable devices unless unavoidable, and CMS expects facilities to document, monitor and trace any permitted use.
Where the process fell short
It was not an emergency: the procedure was elective, and the missing plate created a readiness problem—not an urgent clinical crisis.
The device was an implant: the replacement plate was not processed through a full cycle before use.
The deviation was not closed-loop: the shortcut was reportedly not disclosed to the patient or to later physicians.
The jury found negligence related to sterilization and failure to disclose material information.
The second failure: communication
Gleeson learned months later—from another physician—that the plate had been flash sterilized. When infection developed, subsequent physicians reportedly did not have that information available to them.
Traceability is not only a documentation exercise. When a reprocessing deviation occurs, the information must reach the surgeon, the patient, infection prevention, risk management and every clinician who may later treat the patient.
The human cost
Gleeson underwent 14 surgeries for infection—11 on his right leg and three on his left. Reports describe years of anxiety, panic attacks and depression. Medical testimony indicated that, without the injury, he might have played another decade or more.
On March 28, 2025, a jury awarded more than $20 million. Athletic Business reported the total as $20.6 million, including $15 million in non-economic damages and more than $4 million in past and future wage loss.
Five lessons for sterile processing teams
Never flash implants for convenience. Reserve IUSS for a true, documented emergency. If a case is elective, wait for the full validated process.
Own the missing item. Strong loaner and implant tracking can find a missing plate before it becomes a patient-safety decision.
Empower a stop. Anyone—including SPD staff—must be able to pause a case when sterility or traceability is in doubt.
Disclose every deviation. Document and communicate reprocessing exceptions to the surgeon, patient and downstream care team.
Lead from the top. Executives should understand the real operating condition of their Sterile Processing Department before a crisis exposes it.
Jake Gleeson speaking at HSPA 2026
The takeaway
Jake Gleeson’s story is a reminder that sterile processing is not behind-the-scenes support. It is a direct patient-safety function.
When a sterilization concern arises:
Pause the procedure.
Make the concern safe to report.
Escalate it without blame.
Document the decision and the deviation.
Close the loop with the patient and every relevant clinician.
One missing plate should never become fourteen surgeries.
Desiree Acedo and Jake Gleeson at HSPA 2026
Find the gaps before a patient does
Ready Point Healthcare provides on-site Sterile Processing Department assessments for hospitals and healthcare organizations. We measure practices against current standards and regulations and provide a written report with practical findings.
Book a free facility assessment:Desiree Acedo, CEO702-326-0437desiree@readypointhealthcare.comreadypointhealthcare.com
Sources
Kafoury McDougal, verdict summary (March 2025); Athletic Business, “MLS Team Doctor’s Rush to Perform Surgery on Player Leads to $20.6M in Damages”; Becker’s ASC; ESPN; Moab Healthcare; CMS Survey and Certification Letter 14-44 on immediate-use steam sterilization; CDC Guidelines for Disinfection and Sterilization; ANSI/AAMI ST79.
This article is educational and is not legal or clinical advice. Facilities should follow current manufacturer instructions, applicable regulations and their organization’s policies.
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