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Archive September 2019 XX, No. 9

Patient Safety: Solving Problems That Were Large in Scope

Flexible endoscopes were a potential patient safety issue at Baystate Medical Center. Now? Not so much.

Joe Paone

Joe Paone


Kathleen Roy/Michael Gudejko, Baystate Medical Center
EXPERT CARE In Baystate's renovated scope cleaning room, a specially trained endoscope reprocessing technician gets another scope ready for reuse.

Flexible endoscopes are notoriously difficult to clean, putting unsuspecting patients at risk of being exposed to infections by unsuspecting physicians. After a serious flexible endoscope reprocessing error at Baystate Medical Center in Springfield, Mass., the facility’s staff knew it had to immediately improve its entire high-level disinfection (HLD) process. Their efforts earned this year’s OR Excellence Award for Patient Safety.

Diane Betti, RN, MSN, CNOR, CSPDT, ST, and her team took on the task. They audited the situation and found numerous issues. “We didn’t have consistency in process,” says Baystate’s director of inpatient surgery, perianesthesia and sterile processing. “There were inconsistencies in the handling, transport and delivery of flexible scopes.”

The team delved into where in the process there could be potential breakdowns, assigning a code to each one that reflected the potential for it to result in patient harm. For example, a scope that wasn’t cleaned correctly would be assigned a different weight than mistakes in documentation.

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