During a routine screening in 2010, personnel at Wake Forest Baptist Medical Center in North Carolina discovered Bacillus cereus bacteria in samples dispensed by their machine, the Intellifill IV. Personnel discovered the contamination through quality assurance measures recommended by the manufacturer.
The investigators traced the contamination to the machine’s washing station and the tubing associated with it. Because this area is not considered a sterile part of the robot, the manufacturer does not specify a cleaning procedure for these parts beyond regular “fogging” with alcohol, using a spray bottle to clean inaccessible parts. Although no patients were harmed by the contaminated drugs, the investigation into how the machine became contaminated suggests that the current cleaning and maintenance recommendations may need to be strengthened.
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