Human error source of Denver hospital's sterilization breach

Hospital officials at Porter Adventist Hospital on April 12 identified human error as the source of an infection control breach that potentially exposed 5,800 orthopedic and spine surgery patients to infection, reports Fox31.  

Officials said the errors occurred during the pre-cleaning process, in which staff soak and scrub orthopedic and spine surgery tools prior to machine cleaning and heat sterilization. The tools were not being cleaned properly and potentially contained bioburden, such as pieces of bone or tissue, according to the report.

"Those instruments tend to be highly complex," Porter Adventist CMO Patty Howell, MD, told Fox31. "There'’s a lot of nooks and crannies, sharp areas, mechanisms, that exist in those. Staff was doing cleaning, but they felt there should be more cleaning."

The hospital discovered the sterilization issues Feb. 20 after The Joint Commission visited the facility. Porter Adventist fixed the cleaning process the same day, but did not notify patients of the breach or suspend surgeries for six weeks. 

"When the Joint Commission first identified the issue, it was not identified as an issue that caused patient harm," Centura Health Senior Vice President Morre Dean told Fox31. "Part of the reason we extended the notification period of patients was continued feedback on our process from [Colorado Department of Public Health and Environment] that we're still not to the place we feel like we're perfect. And we might as well include those people."

The CDPHE confirmed surgical infections in "a number of patients" who underwent surgery between July 21, 2016, and Feb. 20, 2018.

Porter Adventist resumed surgeries on a limited schedule April 12.

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