8 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J U N E 2 0 1 7
There's a very narrow margin of safety in endoscope reprocess-
ing. There are more outbreaks from the use of endoscopes than
any other medical device. Flexible endoscopes are fundamentally
difficult to clean and disinfect. Any slight deviation can lead to
survival of microorganisms and risk of infection. Here are a few
headlines that got their start in the reprocessing room:
• In May 2009, the Veterans Administration notified more than
11,000 patients that had colonoscopies performed of potential
exposure to infectious body fluid after officials discovered that
MAJ-855 tubing used with the Olympus Flushing Pump had been
fitted with a two-way valve instead of the one-way valve designed
to prevent contamination.
• In January 2010, Tulane Medical Center in New Orleans noti-
fied 360 patients that had GI endoscopy procedures of potential
exposure to infectious diseases. For 7 weeks, the high-level disin-
fectant was not at a sufficient temperature.
• In July 2012, a jury decided in a class-action lawsuit that
Forbes Regional Hospital was negligent in failing to properly
clean colonoscopes used on more than 225 patients in 2004 and
2005. In 2004, the facility received 2 new colonoscopes and failed
to follow the enclosed instructions that the auxiliary water chan-
nels required special cleaning.
• In April 2013, an Atlanta outpatient surgery center notified 456
patients that they may be at risk for hepatitis and HIV due to
improper cleaning of colonoscopy equipment. Techs cleaned the
scopes with enzymatic detergent with every use, but failed to
high-level disinfect them.
• In January 2014, Seattle Children's Hospital notified the par-
ENDOSCOPY IN THE NEWS
Small Reprocessing Lapses Spell Big Trouble
