Background
Most cases of microbial transmission to patients via contaminated endoscopes have
resulted from nonadherence to reprocessing guidelines. We evaluated the occurrence,
features, and implications of reprocessing lapses to gauge the nature and breadth
of the problem in the context of widely available and accepted practice guidelines.
Methods
We examined peer-reviewed and non-peer-reviewed literature to identify lapses reported
in North America during 2005 to 2012 resulting in patient exposure to potentially
contaminated gastrointestinal endoscopes.
Results
Lapses occurred in various types of facilities and involved errors in all major steps
of reprocessing. Each lapse continued for several months or years until the problem
was discovered except for one that was described as a single incident. There were
significant implications for patients, including notification and testing, microbial
transmission, and increased morbidity and mortality. Only 1 reprocessing lapse was
found in a peer-reviewed journal article, and other incidents were reported in governmental
reports, legal documents, conference abstracts, and media reports.
Conclusion
Reprocessing lapses are an ongoing and widespread problem despite the existence of
guidelines. Lack of publication in peer-reviewed literature contributes to the perception
that lapses are rare and inconsequential. Reporting requirements and epidemiologic
investigations are needed to develop better evidence-based policies and practices.
Key Words
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Article info
Publication history
Published online: September 09, 2013
Footnotes
Ofstead & Associates, Inc. has received funding from Johnson & Johnson and 3M Company for infection prevention studies. Research reported here was supported with internal resources from Ofstead and Mayo Clinic. Outside corporations did not have access to data and were not involved in manuscript preparation.
Conflicts of interest: C.L.O. has received honoraria from Johnson & Johnson and 3M Company for speaking engagements related to instrument reprocessing. A.M.D.L., C.L.O., N.J.M., and H.P.W. are employed by Ofstead & Associates, Inc. The remaining authors disclose no conflicts.
Identification
Copyright
© 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
