Pennsylvania Health Department investigators say a nurse who didn't realize flexible endoscopes must undergo high-level disinfection between cases used a dirty scope during a percutaneous endoscopic gastrostomy (PEG) performed at Chester-Crozer Medical Center in Chester, Pa.
The endoscopy in question occurred in the medical center's surgical department on Saturday, Jan. 7. When the endoscope employed at the start of the procedure failed to work properly, the nurse believed a second scope that had been pre-cleaned, but not disinfected, could be used to complete the case, according to the state's investigative report.
The nurse had been hired in May 2016 and completed orientation for assisting during PEG, but state inspectors did not find documentation that the nurse had competencies for endoscope use and cleaning. In addition to misunderstanding proper scope reprocessing practices, the nurse was apparently unaware that OR staff had access to disinfected endoscopes stored in the medical center's endoscopy suite, even though the department was closed for the weekend.
State inspectors determined the nurse did not follow Chester-Crozer's policies for disinfecting endoscopes prior to reuse. On Jan. 8, the facility halted further endoscopy procedures performed outside the endoscopy suite and completed staff re-education and competency testing on Jan. 13. The state's report did not provide information about the patient's condition.
In a statement, Crozer Keystone Health System says it has concerns about the accuracy of some of the information included in the report, but is cooperating fully with the investigation. The health system also says it is awaiting a response to the corrective action plan it submitted to the health department. A health-system spokesman declined to comment further when reached by Outpatient Surgery Magazine.