Endoscope processing errors more
widespread
VIEWPOINT
by Julie E. Williamson
T
he Department of Veterans Affairs’ Buyer, who requested the IG to become pliance and promote targeted staff train-
recent endoscope reprocessing mis- involved following the Miami incident, ing. A study released at the 2009 SGNA
takes have reached far beyond the said he had suspected that the problem annual conference highlighted facilities’
several initial headline-making facilities. was systemic. “Now that we know it is, I shortcomings. The study, led by Cori L.
A new report from the VA’s Office of the am deeply concerned that this problem is Ofstead, MSPH, of the healthcare research
Inspector General, which was based on the expansive and goes well beyond VA.” firm Ofstead & Associates Inc., and spon-
findings of surprise inspections of 42 ran- sored by Advanced Sterilization Products,
domly selected VA facilities, revealed that Problems not just revealed that while written endoscope re-
half of the sites demonstrated multiple safety
limited to VA
processing guidelines were in place at the
violations related to flexible endoscope re-
Findings from another study – along with
study’s participating sites, significant
processing. The goal of the broader nation-
random anecdotal accounts of endoscope
variations in manual processing still oc-
wide report — requested by Congressman
processing mishaps – seem to confirm
curred, thereby leading to inconsistent GI
Steve Buyer, who serves as ranking member
Buyer’s suspicions.
endoscope reprocessing practices.
of the House Committee on Veterans Affairs
While reprocessing errors can occur in
The majority of endoscopes (using tra-
— was to ensure that employees were famil-
virtually any facility, it’s difficult to assign
ditional reprocessing techniques) were not
iar with, and adherent to, proper equipment
a reliable number to those mistakes because
reprocessed in accordance with existing re-
cleaning and reprocessing procedures.
most incidents never make headlines, and
processing guidelines, according to the
Investigators discovered that in 22 sites
in many cases, staff and patients aren’t even
study’s findings. Specifically, there were
employees failed to demonstrate proper
aware that errors have occurred. Still, a lack
significant inconsistencies in brushing, de-
knowledge and procedural compliance, and
of acknowledgment does not make these
tergent flushing, rinsing, alcohol flushing,
fewer than half of the inspected VA facilities
mistakes any less significant.
and forced air drying times. Brush times
that use endoscopes had posted proper
Perhaps the most effective means of stav-
ranged from ten seconds to two-and-a-half
cleaning guidelines for the equipment. Fur-
ing off endoscope reprocessing errors and
minutes; detergent flush times ranged
ther, these facilities lacked documentation
promoting patient safety is to ensure that
from 18 seconds to two minutes and forty-
verifying that staff was properly trained in
staff consistently and diligently adheres to
five seconds; rinsing times ranged from 75
such procedures.
current endoscope reprocessing guidelines.
seconds to three minutes and 20 seconds;
The IG’s findings led subcommittee lead-
Although the risks of infection from a gas-
alcohol flushes were only documented in
ers Chairman Harry Mitchell and ranking
trointestinal endoscope are small – approxi-
39.5% of instances; and forced air was used
member Phil Roe, M.D., to demand that the
mately 1 in 1.8 million or less – the number
in 81.5% of instances.
VA immediately rectify the problem at all
of episodes of reported infection transmis-
“It is IAHCSMM’s belief that any indi-
facilities through the implementation of
sion falls to zero when cleaning and high-
vidual responsible for endoscope repro-
training and the adherence of stringent pro-
level disinfection are performed properly, in
cessing should have ready access to endo-
cedures. A 90-day follow-up audit was also
accordance with published guidelines from
scope reprocessing guidelines,” said
ordered.
the Society of Gastroenterology Nurses and
IAHCSMM’s educational director Natalie
“These numbers are alarming and unac-
Associates Inc. and the American Society for
Lind, adding that healthcare facilities must
ceptable,” Roe stated. “I am appalled that
Gastrointestinal Endoscopy.
also have stringent policies in place to en-
months after this issue first came to light,
But as the VA incidents demonstrated,
sure that those guidelines are fully under-
more than half of the sites visited were still
not all healthcare institutions are doing
stood and consistently followed.
not compliant with safety procedures.”
what’s necessary to ensure standards com-
Beyond that, processing professionals
should work closely with their vendor
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under toilet for infection control. viewed as an ongoing endeavor,” Lind
Distributed by:
continued. “It’s not enough to teach staff
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0908-Viewpoint.pmd 30 7/13/2009, 11:04 AM
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