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Subscribe:Subscribe to American Journal of Infection Control
- Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008.Department of Health and Human Services, Washington [DC]2008
- Transmission of infection by gastrointestinal endoscopy and bronchoscopy.Ann Intern Med. 1993; 118: 117-128
- Standards of infection control in reprocessing of flexible gastrointestinal endoscopes.Society of Gastroenterology Nurses and Associates, Inc, Chicago [IL]2012
- Multisociety guideline on reprocessing flexible GI endoscopes: 2011.Infect Control Hosp Epidemiol. 2011; 32: 527-537
- Use and reprocessing of flexible fiberoptic endoscopes at VA medical facilities. Report No.: 09-01784-146.Department of Veterans Affairs, Washington [DC]2009
- Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment.Infect Control Hosp Epidemiol. 2012; 33: 649-656
- Infection control assessment of ambulatory surgical centers.JAMA. 2010; 303: 2273-2279
- Endoscope reprocessing methods: a prospective study on the impact of human factors and automation.Gastroenterol Nurs. 2010; 33: 304-311
- The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy.Arch Intern Med. 2010; 170: 1752-1757
- Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography.Endoscopy. 2010; 42: 895-899
- Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009.Euro Surveill. 2010; 15: 1-6
- Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy.World J Gastroenterol. 2006; 12: 3953-3964
- Re-evaluating endoscopy-associated infection risk estimates and their implications.Am J Infect Control. 2013; 41: 734-736
- Escondido: PPH testing 3,400 patients when only 45 at risk of exposure.The San Diego Union-Tribune, June 15, 2010 (Available from: http://www.utsandiego.com/news/2010/Jun/15/escondido-pph-testing-3400-patients-when-only-45/. Accessed January 21, 2011)
- Hospital’s surgical tool was improperly sterilized.The San Diego Union-Tribune, June 13, 2006 (Available from: http://www.utsandiego.com/uniontrib/20060613/news_1m13scripps.html. Accessed May 16, 2012)
- When your best is not good enough.Gastroenterol Nurs. 2010; 33: 62-64
- New Jersey ambulatory surgery center and surgical practice transparency report. New Jersey Health Care Quality Institute, Pennington [NJ]2011
- The dirt on flexible endoscope reprocessing.7. Pennsylvania Patient Safety Advisory, Harrisburg [PA]2010: 135-140
- Inadequate reprocessing of semicritical instruments.California Department of Health Services, Sacramento [CA]2007
Lesher L, DeVries A, Danila R, Harper J. Reported endoscope reprocessing breaches, Minnesota, 2010-2011. San Antonio [TX]: APIC 2012 Annual Conference; June 4-6, 2012.
Food and Drug Administration. FDA looks to improve design and cleaning instructions for reusable medical devices. April 29, 2011. Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm253108.htm. Accessed November 9, 2012.
Giving scopes a clean bill of health. Infection Control Today; April 16, 2008. Available from: http://www.infectioncontroltoday.com/articles/2008/04/giving-scopes-a-clean-bill-of-health.aspx. Accessed January 27, 2011.
Minn. GI center warns of improperly sterilized scopes. EndoNurse; July 6, 2010. Available from: http://www.endonurse.com/news/2010/07/minn-gi-center-warns-of-improperly-sterilized-scopes.aspx. Accessed August 15, 2013.
- 75 St. Clair Hospital patients treated with unsterile device.Pittsburgh Tribune-Review, November 24, 2010 (Available from: http://triblive.com/x/pittsburghtrib/news/pittsburgh/s_710662.html#axzz2bz3QsI8G. Accessed August 11, 2011)
Sullivan M. Task force on adverse health events background documents. December 2, 2008. Available from: http://www.gov.nl.ca/ahe/additions/backgroundweb.pdf. Accessed August 11, 2011.
- Interim report on Ottawa public health's response to the community infection control lapse. Report No.: ACS2012-OPH-IQS-001.Ottawa Board of Health, Ottawa [ON]2012
- Kamloops patient notification letter.Interior Health Authority, Kelowna [BC]2010
- Ass out: local hospital snafus hint at a larger problem.San Francisco Bay Guardian News, 2005 (Available from: http://www.sfbg.com/39/17/news_ass.html. Accessed January 21, 2011)
WFMD. A hospital in Oregon hasn't been sterilizing their colonoscopy scope between patients. January 12, 2011. Available from: http://www.wfmd.com/pages/TMNE.html?article=8034236. Accessed January 21, 2011.
Tsikitas I. 500 patients potentially exposed to contaminated scope at Victoria Hospital. Outpatient Surgery Magazine; April 18, 2010. Available from: http://www.outpatientsurgery.net/news/2010/04/18-500-patients-potentially-exposed-to-contaminated-scope-at-victoria-hospital. Accessed February 17, 2011.
- Backgrounder: ERCP scope reprocessing and infection control.Vancouver Island Health Authority, Victoria [BC]2010
- In Asheville, 10 Mission patients urged to seek viral testing.Asheville Citizen-Times, May 18, 2012 (Available from: http://www.citizen-times.com/article/20120519/NEWS/305190033/In-Asheville-10-Mission-patients-urged-seek-viral-testing?nclick_check=1. Accessed May 25, 2012)
- Mission Hospital identifies a cleaning issue with endoscopic scope. WSPA Channel 7 News, May 19, 2012 (Available from: http://www.wspa.com/story/21515769/mission-hospital-identifies-a-cleaning-issue-with-endoscopic-scope. Accessed May 25, 2012)
- An outbreak of carbapenem-resistant Klebsiella pneumoniae infections associated with endoscopic retrograde cholangiopancreatography (ERCP) procedures at a hospital.Am J Infect Control. 2010; 38: e141
- Patients not infected after tests with dirty equipment: health authority.Pharmacy News, October 20, 2010 (Available from: http://www.guelphmercury.com/news-story/2697981-patients-not-infected-after-tests-with-dirty-equipment-health-authority/. Accessed January 21, 2011.)
- Ochsner Medical Center, Jefferson Highway Endoscopy Lab audit shows small number of endoscopes did not complete high level disinfection process.Ochsner Health System Update, New Orleans [LA]2011
- Candor praised in scope problems.Pittsburgh Tribune-Review, April 1, 2005 (Available from: http://triblive.com/x/pittsburghtrib/news/pittsburgh/s_319469.html#axzz2bzGXfFIA. Accessed January 5, 2011.)
- St Charles: colonoscope not fully sanitized.KTVZ News, January 11, 2011 (Available from: http://www.ktvz.com/news/St-Charles-Colonoscope-Not-Fully-Sanitized/-/413192/622490/-/c3xp3fz/-/index.html. Accessed November 15, 2011.)
- Endoscope reprocessing and infection control. Interior Health Authority, Kelowna [BC]2010
- Ochsner: hundreds of endoscopies may not have gone through full cleaning process. WWLTV News, April 19, 2011 (Available from: http://www.wwltv.com/home/Ochsner-Hundreds-of-endoscopies-may-not-have-gone-through-full-cleaning-process-120239574.html?commentPage=1#comments. Accessed May 5, 2011.)
- Evans Surgery Center warns patients may be infected.WRDW-TV Augusta News, March 5, 2009 (Available from: http://www.wrdw.com/home/headlines/40805497.html. Accessed August 9, 2011.)
- Clinic reports lapses in disinfection: patients are at minimal risk, health officials say.Las Vegas Sun, December 31, 2008 (Available from: http://www.lasvegassun.com/news/2008/dec/31/clinic-reports-lapses-disinfection/. Accessed November 15, 2011)
- Letter to patient.Tulane Medical Center, New Orleans [LA]2011
- Infection risk “remote” after Carbonear hospital equipment problem: Eastern Health.CBC News, April 16, 2009 (Available from: http://www.cbc.ca/health/story/2009/04/16/eastern-health-416.html?ref=rss. Accessed January 27, 2011.)
Hospital malpractice press release: Weitz & Luxenberg responds to report on hospital bacteria outbreak. February 1, 2007; Available from: http://www.weitzlux.com/malpractice/bacteriaoutbreak_435576.html. Accessed August 12, 2011.
- Scope washer malfunction causes concern at Eastern Health. The Telegram, April 16, 2009 (Available from: http://www.thetelegram.com/Health/2009-04-16/article-1452317/Scope-washer-malfunction-causes-concern-at-Eastern-Health/1. Accessed September 1, 2011.)
1310News Staff. Ottawa Public Health reveals site of possible HIV/Hepatitis exposure. 1310News; October 17, 2011. Available from: http://www.1310news.com/2011/10/17/ottawa-public-health-reveals-site-of-possible-hivhepatitis-exposure-3/. Accessed November 1, 2011.
- Advanced Sterilization Products Evotech System Evotech Endoscope Cleaner and Reprocessor. MDR Report Key No.: 1545037.Food and Drug Administration, Silver Spring [MD]2009
- Colonoscopy patients put at infection risk.MedPage Today, April 1, 2005 (Available from: http://www.medpagetoday.com/Gastroenterology/ColonCancer/815. Accessed January 5, 2011)
- Review of the infection prevention and control and CSR sterilization issues in the East Central Health Region.Health Quality Council of Alberta, Calgary [AB]2007
- Ottawa’s public health names clinic at heart of infection scare.Toronto Sun, October 17, 2011 (Available from: http://www.torontosun.com/2011/10/17/ottawas-public-health-names-clinic-at-heart-of-infection-scare. Accessed November 1, 2011)
- Negligent sterilization alleged.Edmonton Journal, July 27, 2007 (Available from: http://www.canada.com/nationalpost/news/story.html?id=0e0fb0aa-87d9-45ca-9285-cbbadc947b5c&k=65295. Accessed January 21, 2011)
- 9,000 B.C. patients warned of surgical tools.CBC News, December 8, 2010 (Available from: http://www.cbc.ca/canada/british-columbia/story/2010/12/08/bc-surgical-tools-kamloops.html. Accessed January 27, 2011)
Sanderson R. An outbreak of carbapenem-resistant Klebsiella pneumoniae infections associated with endoscopic retrograde cholangiopancreatography (ERCP) procedures at a hospital. New Orleans [LA]: APIC 2010 Annual Conference; July 11-15, 2010.
- Dirty instrument did not infect 463 other patients in Victoria.Vancouver Sun, October 24, 2010 (Available from: http://www.canada.com/vancouversun/news/westcoastnews/story.html?id=80df42eb-5cba-44ed-bbc9-1d1d1c79b66d. Accessed January 20, 2011)
DePasquale JM, Endimimani A, Forero S, Roberts D, Fiorella P, Pickens N, et al. Outbreak of carbapenem-resistant Klebsiella pneumoniae infections in a long-term acute care hospital: Florida, 2008. Atlanta [GA]: CDC 58th Annual EIS Conference; April 20-24, 2009.
- Patient-to-patient transmission of hepatitis C virus (HCV) during colonoscopy diagnosis.Virol J. 2010; 7: 217
- SA patients at risk from colonoscope.Nine MSN News, October 18, 2011 (Available from: http://www.news.com.au/breaking-news/sa-patients-at-risk-from-colonoscope/story-e6frfku0-1226169848523. Accessed April 11, 2012)
- Emergence of glutaraldehyde-resistant Pseudomonas aeruginosa.Infect Control Hosp Epidemiol. 2011; 32: 1173-1178
- Analysis of the air/water channels of gastrointestinal endoscopies as a risk factor for the transmission of microorganisms among patients.Am J Infect Control. 2012; 40: 913-916
- Effectiveness of flexible gastrointestinal endoscope reprocessing.Infect Control Hosp Epidemiol. 2013; 34: 309-312
American Medical Association. JAMA instructions for authors. Available from: http://jama.jamanetwork.com/public/instructionsForAuthors.aspx. Accessed July 31, 2012.
Healthcare Infection Society. Journal of hospital infection guide for authors. Available from: http://www.elsevier.com/wps/find/journaldescription.cws_home/623052/authorinstructions. Accessed July 31, 2012.
- Outbreak of Pseudomonas aeruginosa surgical site infections after arthroscopic procedures: Texas, 2009.Infect Control Hosp Epidemiol. 2011; 32: 1179-1186
- Doubt and proof: the need to verify the cleaning process.Biomed Instrum Technol. 2012; : 49-54
- Current limitations about the cleaning of luminal endoscopes.J Hosp Infect. 2013; 83: 22-29
- Establishing a clinically relevant bioburden benchmark: a quality indicator for adequate reprocessing and storage of flexible gastrointestinal endoscopes.Am J Infect Control. 2011; 40: 233-236
- Development and validation of rapid use scope test strips to determine the efficacy of manual cleaning for flexible endoscope channels.Am J Infect Control. 2012; 40: 860-865
- Effect of bowel preparation and colonoscopy on post-procedure intestinal microbiota composition.Gut. 2006; 55: 1822-1823
- Standard colonic lavage alters the natural state of mucosal-associated microbiota in the human colon.PloS One. 2012; 7: e32545
Cautillo C. Three claimants in Farazli suit learn they have Hep. C. CTV News; November 17, 2011. Available from: http://ottawa.ctv.ca/servlet/an/local/CTVNews/20111116/OTT-hep-c-results-farazli-111116/20111117/?hub=OttawaHome. Accessed December 3, 2011.
- Ottawa says 6,800 exposed to infection risk.CBC News, October 15, 2011 (Available from: http://www.cbc.ca/news/canada/ottawa/story/2011/10/15/ottawa-public-health.html. Accessed October 15, 2011)
- Four Farazli patients test positive for hepatitis C.Ottawa Citizen, November 16, 2011 (Available from: http://globalnews.ca/news/178705/four-farazli-patients-test-positive-for-hepatitis-c/. Accessed November 17, 2011)
- Ochsner Health System notifies 222 patients of potential errors sanitizing endoscopes.The Times-Picayune, April 19, 2011 (Available from: http://www.nola.com/health/index.ssf/2011/04/ochsner_health_system_notifies.html. Accessed April 29, 2011)
- Bend Hospital notifies patients of equipment malfunction.OPB News, January 13, 2011 (Available from: http://news.opb.org/article/bend-hospital-notifies-patients-equipment-malfunction/. Accessed February 3, 2011)
- St. Charles Health still scheduled for trial over alleged failure to disinfect colonoscope.Becker’s Hospital Review, April 21, 2011 (Available from: http://www.beckershospitalreview.com/quality/st-charles-health-still-scheduled-for-trial-over-alleged-failure-to-disinfect-colonoscope.html. Accessed April 29, 2011)
- Tulane Medical Center puts patients at risk for hepatitis B, C & HIV.WGNO ABC26 News, March 10, 2011 (Available from: http://www.latimes.com/topic/wgno-news-lawsuit-tulane-medical-center,0,2378174.story?track=rss-topicgallery. Accessed March 15, 2011)
- Lawsuit: Tulane failed to sterilize endoscope: patients sue for exposure to diseases. WDSU-NBC New Orleans, March 11, 2011 (Available from: http://www.nbc33tv.com/news/lawsuit-tulane-failed-to-sterilize-endoscope. Accessed March 15, 2011)
- Tulane Medical Center alerts patients after medical gear improperly sterilized.The Times-Picayune, March 10, 2011 (Available from: http://www.nola.com/health/index.ssf/2011/03/tulane_medical_center_alerts_p.html. Accessed March 15, 2011)
- Ctvbc.ca. 500 at risk from contaminated endoscopes in B.C. CTV News Winnipeg, April 22, 2010 (Available from: http://bc.ctvnews.ca/500-at-risk-from-contaminated-endoscopes-in-b-c-1.504883. Accessed January 20, 2011)
- HCMC tells 2,600 patients device wasn’t properly disinfected.The Star Tribune, June 22, 2010 (Available from: http://www.startribune.com/lifestyle/health/96944634.html. Accessed July 16, 2010)
- Hospital sends letters to 3,400 patients about possible endoscopic equipment contamination.HealthLeaders Media, June 16, 2010 (Available from: http://www.healthleadersmedia.com/content/QUA-252543/Hospital-Sends-Letters-to-3400-Patients-About-Possible-Endoscopic-Equipment-Contamination.html. Accessed January 27, 2011)
- Patients at 2 North County hospitals potentially exposed to viruses: hundreds urged to get tested for hepatitis, HIV because of improperly cleaned equipment. KGTV 10 News, June 14, 2010 (Available from: http://www.10news.com/news/patients-at-2-north-county-hospitals-potentially-exposed-to-viruses. Accessed August 9, 2011)
- Thousands of RIH patients notified about scope disinfection problems.Merritt News, December 10, 2010 (Available from: http://www.merrittnews.net/article/20101210/MERRITT0101/312109964/thousands-of-rih-patients-notified-about-scope-disinfection-problems. Accessed August 9, 2011)
- Evans surgery center sends warning letter to 1,300 patients. The Augusta Chronicle, March 4, 2009 (Available from: http://chronicle.augusta.com/stories/latest/lat_500650.shtml. Accessed January 10, 2011)
- Doctors Hospital Surgery Center LP v. Webb Report No. A10A1317. Court of Appeals of Georgia, Atlanta [GA]2010
- LV surgery center notifying patients.Las Vegas Review-Journal, January 1, 2009 (Available from: http://www.reviewjournal.com/news/lv-surgery-center-notifying-patients. Accessed November 15, 2011)
- CBC News. Alberta hospital closed after superbug, sterilization problems. CBC News, March 20, 2007 (Available from: http://www.cbc.ca/news/canada/edmonton/story/2007/03/20/vegreville-hospital.html. Accessed August 11, 2011)
- Vegreville hospital lawsuit expected.Sun Media, March 24, 2007 (Available from: http://chealth.canoe.ca/channel_health_news_details.asp?news_id=20454&channel_id=1020. Accessed August 11, 2011)
10News.com. Nurse fired for not properly sterilizing surgical instrument. KGTV 10 News; May 2, 2006. Available from: http://www.10news.com/lifestyle/health/nurse-fired-for-not-properly-sterilizing-surgical-instrument. Accessed May 16, 2012.
- Hospital mishap may have exposed 300 patients to diseases.KABC-TV, May 4, 2006 (Available from: http://abclocal.go.com/kabc/story?section=news/local&id=4142061. Accessed May 16, 2012)
- Putnam hospital named in class action suit.The West Virginia Record, November 21, 2006 (Available from: http://wvrecord.com/news/186993-putnam-hospital-named-in-class-action-suit. Accessed February 8, 2011)
- Monroeville hospital urges 200 colonoscopy patients to get checked for hepatitis, HIV.Pittsburgh Post-Gazette, March 31, 2005 (Available from: http://www.post-gazette.com/stories/local/neighborhoods-east/monroeville-hospital-urges-200-colonoscopy-patients-to-get-checked-for-hepatitis-hiv-576233/. Accessed January 27, 2011)
- VA hospital urges endoscopy patients to get tested.Washington Post, August 24, 2005 (Available from: http://www.washingtonpost.com/wp-dyn/content/article/2005/08/23/AR2005082301187.html. Accessed January 27, 2011)
- Redwood City: Hepatitis fears at Kaiser.SFGate, September 9, 2004 (Available from: http://www.sfgate.com/health/article/REDWOOD-CITY-Hepatitis-fears-at-Kaiser-2726821.php. Accessed November 11, 2011)
- Inadequate endoscope reprocessing.Minnesota Department of Health, St Paul [MN]2012
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.