Sterilization lapse at Royal Alex clinic

Health services contacts 141 fertility patrons due to missing documentation

A “possible lapse” in cleaning and disinfecting probes used to perform endovaginal ultrasounds has prompted Alberta Health Services to contact 141 patients of the Royal Alexandra Hospital’s fertility clinic.

Overbooking of procedures and improper documentation Nov. 14 to 20 is to blame for the uncertainty, AHS said Thursday, although the health authority also insisted the risk was “close to zero” that any patient contracted an infection.

“We believe most women would have been examined with a probe that was absolutely cleaned and disinfected, but we just don’t have the documentation to be completely confident of that,” said Dr. Mark Joffe, AHS vice-president and medical director for northern Alberta.

Joffe said the issue was discovered Nov. 20. The clinic had been extremely busy with ultrasound examinations the day before, so AHS decided to check the cleaning and disinfection records.

Joffe said several steps have to be followed before a medical device can be reused — cleaning it, checking it remains functional, disinfecting it and preparing it for the next patient — all of which must be documented.

“There may have been gaps in the process, or gaps in the documentation that those various steps were conducted,” he said. “That was how the event was flagged for us.”

The health authority then checked the records for other days and found similar inconsistencies back to Nov. 14.

No concerns were discovered with the records or the cleaning procedures before that, Joffe said.