IAHCSMM Addresses Lawmakers on Endoscope Mishaps

The International Association of Healthcare Central Service Materiel Management has reached out to Florida and Tennessee legislators to express concern over recent endoscope processing errors that occurred at the Miami Veterans Affairs Healthcare System and the York Veterans Administration Hospital in Murfreesboro, Tenn.

The errors have garnered widespread attention from both the media and the general public, and have underscored the importance of ongoing staff training and due diligence when handling and processing endoscopes. In Florida, the problem arose when irrigation tubing used in endoscopy procedures was rinsed, but not disinfected. With the Tennessee incident, investigations revealed that clinic workers misassembled endoscopic equipment, somehow replacing a one-way valve designed to allow only clean fluids into the tubing with a two-way valve that didn't offer the same protection. Combined, the two incidents led to nearly 10,000 patients being notified that they may have been exposed to hepatitis and HIV as a result.

Last week, updated reports from Veterans Affairs officials revealed that 17 veterans who were treated at the separate VA facilities have tested positive for infectious diseases, including one case of HIV, five of hepatitis B and 11 of hepatitis C. While the U.S. Department of Veterans Affairs has not confirmed a link between the improperly prepared equipment and the infected patients, the agency is conducting epidemiological investigations to determine the possibility of such a connection.

In a letter to Florida Gov. Charlie Crist and senators, IAHCSMM president Lisa Huber stressed that similar errors occur each year throughout the nation – some of which are never publicized, but are nonetheless devastating to the patients, families and healthcare organizations involved. “Such occurrences highlight the patient safety risks and hospital liability issues surrounding endoscope processing errors and underscore the need for ongoing education, staff competency and an overall commitment to quality to prevent similar mistakes from happening in the future.”

Huber further explained that, despite the vital role that sterile processing professionals play in the delivery of safe, quality patient care, the discipline's many contributions continue to be overlooked and underestimated by some healthcare organizations and state health officials.

“It is IAHCSMM's longstanding belief that sterile processing professionals in every facility throughout the nation must receive ongoing, formal training and become certified in order to perform their daily duties effectively,” she noted, adding that, in some facilities across the country, sterile processing professionals are performing this essential function in the absence of any formal training and certification requirements.

Along with the letter, IAHCSMM included its educational DVD, Central Service: Instrumental to Patient Care, and urged the legislators to become a champion of mandatory training and certification of sterile processing/Central Service professionals in their states. “Not only will such efforts go a long way toward driving healthcare quality and reducing the risk of hospital-acquired infections, they will help ensure that equipment-related mistakes, such as those making headlines in recent weeks, will not be repeated,” Huber stated.

For those wishing to contact their own state legislators, IAHCSMM has made a generic letter available on IAHCSMM's Web site (www.iahcsmm.org/MandatoryCertification.html), along with links to senate legislators and congressional representatives.

Source: International Association of Healthcare Central Service Materiel

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