Patients Warned of Infection Risk From Improperly Cleaned Endoscopes

By on 8:40 AM

The Buffalo (N.Y.) Veterans Affairs Medical Center is notifying more than 500 patients of a potential risk of infection due to improper sterilization of endoscopes, according to news reports.

The hospital said one of its employees may not have followed the manufacturer's instructions for disinfection of the reusable equipment. The mistake was discovered during a review of the disinfection process.

The 526 patients at risk of infection underwent procedures at the medical center between April 19, 2015, and June 23, 2017.

Medical center officials have said the infection risk is "very low." They are offering a free screening to these patients.

Proper cleaning of reusable medical devices has been an ongoing issue for the past several years, and was discussed in an Infection Control Consulting Services (ICCS) Special Report. As the report notes, in 2015, the Centers for Disease Control and Prevention (CDC) issued an official Health Advisory to healthcare facilities that use reusable medical devices urging them to "immediately review current reprocessing practices at their facility to ensure they (1) are complying with all steps as directed by the device manufacturers, and (2) have in place appropriate policies and procedures that are consistent with current standards and guidelines."

Another ICCS Special Report on top infection prevention-related CMS survey citations highlighted the failure of facilities, including ambulatory surgery centers and hospitals, to adhere to standards for reprocessing of endoscopes.

In 2016, officials released a 2016 update to a multisociety guideline on reprocessing flexible GI endoscopes.

Also in 2016, the Society of Gastroenterology Nurses and Associates released new and revised infection prevention-focused practice documents intended to address factors that must be followed to help ensure safe and effective GI endoscope reprocessing.

In March 2017, an infection outbreak at a foreign health facility was linked to redesigned Olympus duodenoscopes.

In June 2016, a Maryland hospital reported a possible exposure of patients due to a piece of equipment that "had a defect that might have kept it from being thoroughly disinfected."

ICCS infection prevention services including assisting organizations in the development of processes for cleaning, disinfection and sterilization of reusable medical devices as well as audits of existing processes. To learn more, contact ICCS today.

Phenelle Segal, RN, CIC, FAPIC

Phenelle Segal, RN, CIC, FAPIC, is the founder and president of Infection Control Consulting Services LLC (ICCS). Phenelle has more than 30 years' experience providing customized comprehensive infection control and prevention services to healthcare facilities nationwide. Her services focus on assisting hospitals, ambulatory surgery centers, dental office and oral surgery practices, doctor's offices, nursing homes and other organizations with implementing and maintaining an infection control program that: complies with The Joint Commission, AAAHC, Centers for Medicaid and Medicare Services (CMS) and other regulatory agencies; respond to situations of noncompliance; and improve the processes for reducing risk.