Reprocessing practices at Seattle Children's Hospital are under review by state health authorities after an in-house investigation late last year revealed the inadvertent use of contaminated flexible endoscopes.
While no incidents of cross-contamination illness have been reported to date, the hospital has disclosed that 106 patients were exposed to the improperly cleaned instruments. It has offered blood tests for hepatitis B and C and HIV to patients at risk of infection.
According to news reports, a sterile processing technician discovered bioburden in a reprocessed endoscope's channel in November. A few days later, the residue was found in another scope.
"At that point in time we stopped all colonoscopies and performed an investigation and identified that we had a lapse in our cleaning processes," said Danielle Zerr, MD, MPH, the hospital's medical director of infectious disease.
Dr. Zerr attributed the dirty instruments to a breakdown in staff training. "We feel that we didn't have good systems in place to ensure training of new technicians who were coming into our system," she said.
The scopes' manufacturer has since inspected and re-evaluated the hospital's reprocessing procedures to ascertain their compliance with its cleaning guidelines. The hospital has retrained 20 staffers and has opened its doors to investigation by Washington's health department.
"This is an isolated occurrence that happened," says Dr. Zerr, "but of course that makes you think about where else you might have vulnerabilities."