7/29/2014

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Errors prompt investigation at Seattle Children's Hospital

Errors prompt investigation at Seattle Children's Hospital

SEATTLE -- A breakdown in training left instruments dirty and opened the doors to dangerous infections for more than 100 patients at Seattle Children's Hospital.

Doctors say so far nobody has gotten sick, but the errors launched a State Health Department investigation.

The problem involves colonoscopies, which are used to check for ulcers, tumors and inflammation up to the lower intestine. However, the colonoscopies performed at Seattle Children's hospital may have put young patients at-risk.

In November, a technician discovered a poorly cleaned colonoscope. Another turned up a few days later.

"At that point in time we stopped all colonoscopies and performed an investigation and identified that we had a lapse in our cleaning processes," said Dr. Danielle Zerr, the medical director of infectious disease at Children's.

Dr. Zerr says a patient's "organic material" was still trapped in one of the scope's channels. Hospital staff then identified 106 children who may have been affected, and offered free blood tests to check for infections. They tested for hepatitis B, hepatitis C and HIV, though doctors insist the risk of infection is low.

The scope's manufacturer spells out multi-step cleaning instructions to avoid cross-contaminating patients. Zerr says hospital procedures came up short on those requirements.

"We feel that we didn't have good systems in place to ensure training of new technicians who were coming into our system," she said.

The hospital says it's made changes. Children's had the manufacturer re-inspect the equipment and re-evaluate hospital procedures. They also retrained 20 staffers who handle the scope, put the cleaning protocol to an audit, and reached out to public health officials for assistance.

The State Health Department is now independently investigating the matter.

"Our investigation is really related to their policies and procedures and practices," said Martin Mueller, the assistant secretary of health systems quality assurance with the Department of Health.

While no patients tested have come back infected, the incident raises the question of what else Children's Hospital needs to re-evaluate.

"This is an isolated occurrence that happened, but of course that makes you think about where else you might have vulnerabilities," Zerr said.

The last time the hospital faced an issue like this was in 2010, when an infant died because of a medication error.

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