The transmission of infectious organisms during GI procedures is considered low; however, taking the necessary steps to mitigate this risk is imperative. Failure to follow the recommended cleaning and sterilization of equipment can result in preventable infection.
An important step in this sterilization process is scope reprocessing. Scope reprocessing refers to the validated process of cleaning and then disinfecting or sterilizing colonscopes and accessories. This includes seven steps: pre-cleaning, cleaning, rinsing, disinfection, rinsing, drying, and storage. The reprocessing of scopes should be carried out in accordance with evidence-based protocols for each of the seven steps.
In this case study, we will look at how failure to thoroughly clean equipment and track the use of the scope resulted in a patient having to undergo unnecessary lab work due to potential exposure to infection. We’ll also provide risk management strategies to help avoid a similar situation.
A colonoscopy was performed on a patient with a scope that had been used the previous day on another individual. It was discovered that the scope only went through first phase of the cleaning/sterilization process before being used on this patient.
The patient was notified to return for a recheck and serial blood work given their exposure to the potentially contaminated colonoscope. The physician explained the issue and provided exposure education to the patient. The first round of labs was negative, as was the second round. The patient was notified of this reassuring news.
What Went Wrong?
Compliance with the scope reprocessing procedure was not followed. Since the entire cleaning process was not completed, the patient may have been exposed to infectious body fluids from previous use on another patient. Strict adherence to the scope reprocessing procedure is essential to avoid errors such as this.
Furthermore, the practice did not maintain a record of the scopes that were used on specific patients. Because the scopes were not tracked, the practice could not identify the previous patient and review their medical history and determine risk exposure. This resulted in the patient having to undergo a broad series of lab tests.
Risk Management Takeaways:
- Practices should develop written policies and evidence-based protocols for scope reprocessing.
- Practice leaders should provide staff training and evaluate competency with scope reprocessing.
- Practice managers should review the log recordings for the completion of all reprocessing phases. It is essential to correctly complete the phases before re-using scopes to minimize potential exposure to unknown body fluids. Practices should also develop a process to investigate the breakdown and determine the risk exposure should there be any breaches to reprocessing.
- Practices should develop a tracking system to document the scopes used on individual patients. This tracking will enable physicians to check the patient’s history and determine risk exposure should there be a breach in the scope reprocessing.
To evaluate risk within your practice, Curi members are invited to take our Self Risk Assessments (SRAs), including the newly available GI SRA. Members can click here to begin their SRA today and receive actionable insights and suggestions as developed by our expert team of risk management professionals.
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