Reprocessing included in top 10 patient safety list
Atlanta incident shows potential for mistakes
In 2013, letters were sent to more than 450 patients who had received colonoscopies at an Atlanta surgery center since 2011 warning them that they might be at risk for several diseases because staff weren’t soaking the instruments in high-level disinfectant.1
One of the physicians observed the staff and then asked how they cleaned the instruments, and the missing step was identified.2 The problem was discovered by a doctor who observed the cleaning practices at Piedmont West and questioned the staff. The center’s health care system attributed the problem to communication and management oversight that were lacking.
The center voluntarily reported the action to the state health department. It set up a special phone line for affected patients to call. It sent letters to more than 450 potentially impacted patients and offered testing for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV), and physician counseling at no cost. It identified the risk of transmission as less than one in 1 million and said no patients had reported problems.
Several patients are exposed to endoscopes that undergo improper sanitization every year, according to the Centers for Disease Control and Prevention.2 Between 2004 and 2009, more than 10,000 patients received colonoscopies with improperly cleaned equipment at several Veterans Administration facilities.2
ECRI Institute recently listed "inadequate reprocessing of endoscopes and surgical instruments" in its first list of the top 10 patient safety concerns for healthcare organizations. The list also includes drug shortages, retained devices and unretrieved fragments, and inadequate monitoring for respiratory depression in patients taking opioids.
"The biggest challenge facing the ambulatory setting is that very frequently there are pressures for high volume and quick turnaround," says Gail Horvath, MSN, RN, CNOR, CRCST, patient safety analyst/consultant III, Patient Safety Risk and Quality (PSRQ) patient safety, ECRI Institute, a Plymouth Meeting, PA-based nonprofit organization that examines which medical procedures, devices, drugs, and processes enable improved patient care. If procedures are too rushed, critical steps in the process can be overlooked or omitted, Horvath says.
Another potential problem area is that surgical instruments are much more complex in the past; they have more channels and moving pieces, Horvath says. These complex instruments are more difficult to clean, she says. "Often, staff doesn’t have availability of manufacturer recommendations or instructions for use," she says. "They can be unaware of certain steps that need to be taken."
If the cleaning or reprocessing isn’t done correctly, it increases the risk for patient infection, Horvath says.
To avoid problems, know that properly cleaned, sterile surgical instruments "are the first step in patient safety in any patient area," she says. Ensure you have qualified people performing the cleaning and disinfection of scopes, Horvath advises. Two states now require national certification, and many states have introduced legislation that would require national certification, she points out.
Include the staff members who perform the sterilization in your device purchasing decisions, Horvath says. Including them will help ensure you have proper equipment that can be cleaned and sterilized according to the manufacturers’ instructions, she says.
Finally, give them time, Horvath says. "Ensure that adequate time is allowed for them to be properly processed prior to returning instrument or scope to patient use," she says.
- MyFoxAtlanta. Atlanta surgery center admits error in cleaning colonoscopy equipment. April 30, 2013. Accessed at http://bit.ly/1slUanZ.
- Associated Press. 456 colonoscopy patients at an Atlanta surgery center warned of infection risk. Accessed at http://bit.ly/1mOLpFX.
- ECRI Institute’s Top 10 Patient Safety Concerns for Healthcare Organizations (Full Report). Web: www.ecri.org/EmailResources/PSRQ/Top10/Top10PSRQ.pdf.
- ECRI Institute’s Top 10 Patient Safety Concerns Poster. Web: www.ecri.org/EmailResources/PSRQ/Top10/Top10PSRQ_Poster.pdf.