Improperly sterilized endoscopes cause concern in Halifax
CMAJ 2000;162:1193
Everything looked fine on the surface, but closer examination revealed that endoscopes being used at the Queen Elizabeth II (QE II) Health Sciences Centre in Halifax were not being sterilized properly. As a result, 277 patients who were tested over a 2-week period in December have been informed that there is a chance they may have been infected with HIV or contracted an infectious disease such as hepatitis C. That chance is slim, however — it is literally one in a million, the same odds normally associated with the procedure.
The culprit in this case was a filter in the machine used to disinfect the equipment. It had not been properly fitted and the machine was not able to sterilize the endoscopes completely. The problem was detected because of the hospital's ongoing quality assurance program, which calls for scopes and other equipment to be tested every few weeks. In December the scopes were found to contain bacteria commonly found in the stomach. Tests for viruses were not conducted because they are too fragile to exist outside the body for anything but a brief time. The hospital responded by closing down the the GI clinic temporarily; other sites at the QE II were also examined carefully.
The hospital sent a letter to all patients examined with an endoscope from Dec. 10 to Dec. 23. They were offered tests to detect HIV and hepatitis C, with most patients opting to receive them. "We did have a problem," says Bob Smith, president and CEO of the hospital. "We will from time to time have things that occur that we need to address publicly."
But this public acknowledgement of mistakes, he adds, "is a different way of doing business in the health care system. It is recognition that the goalposts have changed in terms of what our responsibility is to the public. It's a significant ethical and moral shift and an improvement for the QE II." — Donalee Moulton, Halifax
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