Successful surgery does not just depend on the skills and knowledge of those in the operating room but also on the staff that insure the needed instrumentation is available and sterile. The process that continuously provides reusable medical equipment (RME) to the Operating Room (OR) requires highly specialized expertise over a wide range of instrumentation. The reprocessing team must be familiar with instructions for use (IFU), and how to apply them to process every piece of RME from surgeries, endoscopies, and clinic procedures. Coupled with the limitations of staff, time, and resources and with competing demands to produce sterile instruments and environments that work in almost total isolation from each other, there are several gaps in the process that must be identified and bridged. While the workflow for moving between the Sterile Processing Department (SPD) and the OR is sometimes thought as a fairly simple circular flowchart, the realities of work done versus work imagined are vastly different. In addition, these challenges vary considerably across different departments, even in a single healthcare system, and as such there are no simple solutions. Understanding the demands on the SPD, the needs in the OR for sterile RME, and the patient safety concerns that drive this cycle are critical if we are to improve the process.