Health scare for 55 patients
Three children under the age of
16 and four people over the age of
70 are among the patients potentially affected by a failure to properly sterilise surgical equipment at Hawke’s Bay Hospital.
Surgical equipment that had not been fully sterilised was potentially used on 55 patients in Hawke’s Bay.
Those patients will now be tested for blood borne viruses – including HIV and hepatitis B and C – but it will be 24 weeks before the patients can be given the all clear.
Of those, the greatest risk is of hepatitis B and patients will be offered a vaccine for that.
The Hawke’s Bay District Health Board admitted the mistake at a press conference yesterday morning. There were 91 pieces of equipment that were cleaned and heated to high temperatures, but failed to go through the third and final stage of sterilisation overnight between February 1 and 2. That equipment was then distributed to clinics and used by district nurses before the mistake was discovered on Monday, February 11.
Up to 55 patients may have been affected by the mistake.
Of those, 18 people were operated on in the main theatre block of Hawke’s Bay Hospital.
A DHB spokeswoman said there were three children under the age of 16 and four people over 70 among those 18.
Packs were also sent to oral health and gynaecological clinics throughout Hawke’s Bay.
The remaining patients are being identified.
The mistake was identified by a theatre nurse during a safety check on Monday. She discovered that a pack containing equipment was not marked as having been fully sterilised.
Each package has a label that changes colour, from green to black, when the sterilisation process is completed.
More than half the packs that were sent out were recalled before being used.
Chief executive Kevin Snee said there was an ‘‘extremely remote chance’’ patients may have been at risk of infection.
He apologised for any distress caused and said the main concern was identifying and contacting the patients involved.
The DHB’s clinical director of health improvement and equity Dr Nick Jones said: ‘‘The risk was incredibly small but we couldn’t not follow it up’’.
Bacterial infections could be ruled out given the sterilisation process, and patients would only be tested for viral infections.
Jones said the tests would be made available to anyone exposed but not to their families as ‘‘there is no risk to them’’.
‘‘The incubation period for all those diseases is many weeks,’’ he said. Those involved would undergo a series of blood tests; this week, in six weeks and again in 24 weeks.
They would not know conclusively until the last test if they had been infected. A review of processes to date had shown that this was the only occasion where the sterilisation process had not been completed. ‘‘We know the names of everybody who is potentially at risk and we’re contacting everybody. So there’s no need for the general population who’ve had a procedure at Hawke’s Bay Hospital to be concerned,’’ Jones said.
Dr Colin Hutchinson, executive director of provider services, said all patients would be invited to the hospital in the next few days to have care plans explained.
A ‘‘very thorough’’ review was under way to find out how this event occurred.
University of Otago professor Stephen Chambers said it was unlikely any patients would contract an illness, considering only one step in the ‘‘multi-layered’’ sterilisation process failed.