‘Here we go again’

No need for alarm over alarm mal­func­tion: East­ern Health


East­ern Health has fessed up to an­other equip­ment mal­func­tion that could have had an ef­fect on thou­sands of pa­tients in Con­cep­tion Bay North.

Of­fi­cials with East­ern Health an­nounced last Thurs­day af­ter­noon, April 16 it was highly un­likely any one of the 2,900 peo­ple who were tested with a gas­troin­testi­nal scope - which was im­prop­erly cleaned by a mal­func­tion­ing piece of clean­ing equip­ment - are af­fected in a neg­a­tive way.

Of­fi­cials with the health board told re­porters that the ma­chine cleans the scope, which is used to di­ag­nose gas­troin­testi­nal ill­nesses - was only us­ing about one quar­ter of the dis­in­fect­ing so­lu­tion it was sup­posed to. The alarm, which is sup­posed to no­tify tech­nol­o­gists the ma­chine is mal­func­tion­ing, didn’t go off.

It wasn’t un­til a worker at the Carbonear Gen­eral Hospi­tal re­al­ized she hadn’t changed the bot­tle of dis­in­fec­tant in a while, that she re­al­ized some­thing was wrong with the ma­chine.

Fay Matthews, chief op­er­at­ing of­fi­cer of the ru­ral Avalon divi­sion of East­ern Health, says the ma­chine could have been mal­func­tion­ing since Novem­ber 2007.

Af­ter dis­cov­er­ing the prob­lem, Matthews says the ma­chines were shut down, the man­u­fac­turer was called, the other ma­chines were tested and an in­ves­ti­ga­tion was launched by East­ern Health, Health Canada and the man­u­fac­turer.

The other health au­thor­i­ties were also no­ti­fied so they could check their ma­chines.

Dr. Jim Hutchin­son, clin­i­cal chief of the in­fec­tion con­trol pro­gram, says that be­cause the step in the clean­ing process is one of five and the un­like­li­hood that those who were tested with the scope were in­fected, East­ern Health of­fi­cials say the risk is ex­tremely re­mote.

As an ad­di­tional pre­cau­tion, East­ern Health work­ers are cur­rently mea­sur­ing the amount of dis­in­fec­tant used in the clean­ing cy­cles and will be re­plac­ing the ma­chine as soon as pos­si­ble.

Roland But­ler, Lib­eral MHA for Port de Grave, says he was glad to hear East­ern Health came for­ward with the in­for­ma­tion, but says there should have been more warn­ing and sooner that there was a prob­lem.

“To know that this prob­lem was on­go­ing since 2007...you would think there would be some­thing to set off sig­nals,” But­ler says. “When it comes to the health-care sys­tem and equip­ment that’s be­ing used on a reg­u­lar ba­sis like this, you would think there would be some back up more or less, an­other sys­tem that would trig­ger an alarm to go off.

“But here we go again. Peo­ple will have con­cerns I’m sure.”

This isn’t the first time there have been is­sues with the process of scope clean­ing at the Carbonear hospi­tal.

In fact, last year’s Au­di­tor Gen­eral’s re­port looked at in­fec­tions ac­quired by pa­tients in hos­pi­tals, which men­tioned an in­ci­dent at the Con­cep­tion Bay North hospi­tal un­der the pre­vi­ous health board.

At the time, Nose­wor­thy wrote: “gov­ern­ment does not know ei­ther the num­ber of hospi­tal-ac­quired in­fec­tions or the num­ber of deaths re­sult­ing from such in­fec­tions in the prov­ince.”

How­ever, he did cite one ex­am­ple when talk­ing about whether pa­tients were no­ti­fied of their pos­si­ble ex­po­sure. In that case, an im­prop­erly cleaned gas­troin­testi­nal video scope had been used on 72 in­di­vid­u­als in Carbonear un­der the for­mer Avalon Health Care In­sti­tu­tions Board.

In its re­sponse to Nose­wor­thy’s find­ings, the Depart­ment of Health said it would be ad­dress­ing the is­sues.

Mean­while, Fay Matthews says East­ern Health won’t be con­tact­ing any of the 2,900 peo­ple who would have had a test with the scope.

Rather, East­ern Health has set up an in­quiry line and is ask­ing pa­tients who may have ques­tions to call toll free, 1-888945-6558, Mon­day to Fri­day, be­tween 9 a.m. and 5 p.m. Pa­tients may also fol­low up with their fam­ily physi­cians in the re­gion, who have been no­ti­fied along with the other Re­gional Health Au­thor­i­ties.

Bill Bow­man/The Com­pass

A piece of clean­ing equip­ment at this hospi­tal has been dis­cov­ered to be only us­ing about one quar­ter of the dis­in­fec­tant it was sup­posed to. The alarm, which is sup­posed to alert tech­nol­o­gists the ma­chine is mal­func­tion­ing, didn’t go off.

Photo by Alisha Mor­ris­sey/The Tele­gram

Fay Matthews, chief op­er­at­ing of­fi­cer of the ru­ral Avalon divi­sion of East­ern Health, tells re­porters about an alarm mal­func­tion on a scope clean­ing ma­chine at the Carbonear Gen­eral Hospi­tal.

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