An outpatient surgery center owned by Piedmont Healthcare failed to properly clean equipment used in hundreds of colonoscopies, placing patients at risk of serious infection.
The hospital network said the breach involved 456 patients but said the risk of infection was less than one in a million. It mailed letters on Saturday to the affected patients: those who had colonoscopies at Piedmont West Surgery Center between May 2011 and mid-April of this year. Piedmont advised the patients to be tested for hepatitis B, hepatitis C and HIV. The surgery center is at an office building at Howell Mill Road near I-75.
Piedmont said no patient has reported problems.
“As scary as it sounds, statistically the risk of transmission from something like this is actually quite remote,” Dr. Leigh Hamby, Piedmont’s chief medical officer, told The Atlanta Journal-Constitution.
An expert at the U.S. Centers for Disease Control and Prevention in Atlanta confirmed the risks were low, saying there had been no documented cases in the U.S. of patients contracting HIV, or hepatitis B or C as a result of improper cleaning and sanitizing of endoscopes.
Piedmont said the surgery center staff cleaned the endoscopy instruments with enzymatic soap after each use. However, the staff failed to perform the final recommended step of soaking the equipment in a high-level disinfectant.
The problem was discovered by a doctor who observed the cleaning practices at Piedmont West and questioned them, Hamby said. The employee responsible for the breach of protocol resigned in lieu of termination, a Piedmont spokeswoman said.
The patients from Piedmont West made up a fraction of the nearly 17,000 who underwent colonoscopies at all Piedmont facilities during the same time frame. Piedmont examined its cleaning procedures at all of its other locations and found no problems, Hamby said.
Piedmont had set up a special phone line for affected patients to call and has already begun screening them at no charge.
“It’s a big deal to patients getting these letters because it is potentially very frightening and starts making you think, “What if, oh my gosh, this could be a life-changing event,’” Hamby said. “I think the risk of that happening is going to be extremely low.”
The growing complexities of health care have introduced more devices to treatment and also more procedures for handling those devices properly. Keeping patients safe requires health systems to be vigilant about making sure proper processes are understood and followed, while also inviting every staff member to question whether things are being done correctly, Hamby said.
“Our patients have trusted us with their care and we want to make sure we earn that trust every day,” Hamby said.
Joseph Perz, a health care epidemiologist at CDC, said the agency receives several reports a year of patients being exposed to endoscopes that were not properly sanitized. The largest such case involved the Veterans Administration, in which more than 10,000 patients between 2004 and 2009 received colonoscopies with improperly cleaned equipment at numerous facilities.
An Air Force veteran in Miami and his wife won a $1.25 million judgment against the government last fall. The judge in the nonjury trial concluded that it was likely the man had contracted hepatitis C from tainted VA equipment.
Perz said that even though there have been no clearly documented cases, there is an awareness that such transmissions are possible. “I think it says something for the institutions here that they are recognizing the error and trying to do right by patients,” Perz said.
CDC encourages health care providers to adopt systems to avoid these kinds of errors. “I think unfortunately too much of health care is still prone to human error, right?” he said. “So we would like to see institutions strive to make something like endoscope reprocessing as foolproof as humanly possible. There are guidelines and checklists that can be followed.”
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