A state health inspector cited Crozer-Chester Medical Center for allowing an improperly cleaned endoscope to be used in a surgical procedure, exposing the elderly patient to possible infection.
Endoscopes — a group of tubular instruments used to look at various organs inside the body during procedures — are notoriously hard to clean and have been linked to infections, some fatal, at hospitals around the country in recent years. The American Journal of Infection Control reported last month that microbes grew on 60 percent of endoscopes in a small study even after rigorous cleaning.
The Crozer investigation noted that the hospital's endoscopy suite was closed for the weekend when the incident occurred on Saturday, Jan. 7. A Pennsylvania Health Department inspector's interview determined that an employee involved with the surgery "did not know that an endoscope could not be reused if it had only been pre-cleaned and did not understand that it required high level disinfection before reuse," according to the investigative report, which determined that the hospital had failed to follow its own policies.
In a statement Wednesday morning, Crozer Keystone Health System said that it "encourages the immediate reporting of potential safety risks that may occur during patient care. As such, in this case, health system became aware that an employee may not have completely followed protocols related to the high-level disinfection of an instrument used in a procedure at Crozer-Chester Medical Center. We immediately reported this situation to the Department of Health and took numerous actions to ensure the safety of our patients and to provide employees with the necessary re-training."
Neither the hospital nor the state released information about the patient's condition, or whether an infection had resulted. Neither the type nor make of endoscope were identified.