What A Recent Outbreak in a US Military Hospital Can Teach Us
The recent revelation of a potential endoscope-related outbreak at the Al Udeid Air Base in Qatar reminds us once again of the risks that improperly reprocessed scopes represent to our patients. This unfortunate episode potentially exposed 135 airmen to such diseases as HIV, hepatitis B and C and other potentially fatal bugs.
The most disturbing piece of information in this story is that endoscopes were being reprocessed improperly for 8 years. During this time, there were several instances where the cleanings that weren’t following standard sterilization guidelines could have, and should have, been caught. As this article by Saskia V. Popescu of ContagionLive explains:
“The endoscopes were not cleaned according to US Food and Drug Administration (FDA) guidelines and further review found that the medical technicians responsible for disinfection used “an alternate method that included manual cleaning and inspection, rather than the recommended automated process. Specifically, it was noted that during equipment reprocessing, the flushing and brushing of the scope lumens were not completed as recommended by the manufacturer.”
This is particularly concerning on several levels—first, given all the attention that was placed on duodenoscope reprocessing, healthcare facilities have ramped up disinfection monitoring methods for all flexible endoscopes to ensure compliance and avoid adverse events. Was this increased scrutiny not present at the Al Udeid clinic?
Second, how did such poor disinfection practices go unnoticed for 8 years? Validating employee competencies is crucial and should always be ongoing practice. A medical culture that fails to identify these practices or turns a blind eye is extremely concerning. Upon these findings, they should have been doing a substantial deep-dive into all other disinfecting and sterilization practices. (According to the Air Force, they have taken preventive measures at the clinic following the finding, including issuing a patient-safety alert, reviewing procedures, and stopping the associated procedures with the endoscopes.)
Third, how was this violation found? Given the length of time these poor practices persisted, perhaps a shift to a culture of Just-In-Time practices is needed, which highlights drawing attention to near misses as a learning, rather than punitive, tactic.
Lastly, as I mentioned before, it is concerning that this 8-year exposure is not related to a defective or intricate product that caused issues despite proper practices, but rather this was due to poor practices and a complacent approach to monitoring and validation.”
Read the entire article here: The Never-Ending Story of Endoscope Exposures
This story once again reminds us how important it is to inspect what you expect. Without proper examination and verification, the steps that we take for granted every day can be skipped or forgotten by even the most competent staff member. Automated documentation systems such as iRIScope can make the capture and reporting of such steps seamless, while reducing the amount of time sterile processing staff spend documenting their work. Make sure that you work with your team to identify any potential issues in your scope reprocessing workflow, and continue to gather data and provide it back to the team to track their progress to the ultimate goal – 100% patient safety.