Human error source of infection control breach involving 5.8k spine patients at Porter Adventist: 5 things to know

Written by Mackenzie Garrity | April 13, 2018 | Print  |

Denver-based Porter Adventist Hospital admitted human error caused its recent infection breach that may have affected 5,800 spine and orthopedic surgery patients, according to KDVR.

Here are five things to know.

1. CMO Patty Howell, MD, and Centura Health Senior Vice President Morre Dean apologized and explained how the infection breach spread. They did not indicate the exact number of patients affected.

2. All spine and orthopedic surgery tools at Porter Adventist underwent mechanical cleaning and heat sterilization prior to surgery. However, the error occurred when surgical tools were pre-cleaned.

3. Dr. Howell and Mr. Dean indicated the infection breach spurred from the surgical tools not being cleaned properly and potentially containing bioburden. Staff wiped down, soaked and cleaned certain spine and orthopedic instruments, but not to a level needed for proper sterilization.

4. The Joint Commission visited the hospital Feb 20. Following the visit, Porter Adventist was made aware of the infection breach. Porter Adventist fixed the cleaning process the same day and waiting six weeks to tell patients.

5. When Porter Adventist warned patients of the breach, the hospital also suspended surgeries. Since warning patients, the hospital discovered it had issues with a cleaner that would leave mineral deposits on surgical tools. The issue has since been fixed and surgeries have resumed on a limited schedule.

More articles on spine:
Spine surgeon Dr. Johnny Delashaw sues Seattle Times for 2017 report: 5 things to know
Porter Adventist Hospital resumes surgeries after infection control breach: 4 insights
Healthcare's biggest changes over the next 10 years as spine surgeons see it

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