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Originally published January 22, 2014 at 6:48 PM | Page modified January 22, 2014 at 7:52 PM

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Children’s patients may be at risk of infection after colonoscopies

More than 100 patients who had colonoscopies at Seattle Children’s are at potential risk for infection because equipment was not properly cleaned.


Seattle Times staff reporter

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More than 100 patients who had colonoscopies between 2011 and 2013 at Seattle Children’s have been advised to be tested for hepatitis B and C and HIV after the hospital discovered special equipment used in the procedures had not been properly cleaned.

The risk for infection is “very low,” Dr. Danielle Zerr, Seattle Children’s medical director for infection prevention, said Wednesday.

The hospital began notifying the 105 patients late last week.

The cleaning-process lapse was discovered in early November and involved two auxiliary channel scopes specifically used for children’s colonoscopies.

“They noticed one of the scopes was not in the condition it needed to be in before the procedure,” said hospital spokeswoman Stacey DiNuzzo. Eight days later, technicians preparing for another colonoscopy found a second scope that had not been properly cleaned, she said.

Children’s says it then canceled all colonoscopies and started an investigation.

The material found on the scopes should have been flushed, Zerr said, and the scopes sent to another department in the hospital for sterilization within 59 minutes. In addition to not adequately cleaning the scopes, there was a delay in sending them for sterilization within the designated time frame, she said.

The hospital found that technicians weren’t sufficiently trained on the proper procedures, which led to the scopes being used again before they were ready, DiNuzzo said.

The hospital did not inform patients earlier because officials wanted to do a thorough investigation and not unnecessarily alarm patients, Zerr said.

From July 2011 to 2013, the hospital can't be sure that the technicians were cleaning the colonoscopes in the manner they were supposed to, Zerr said. “These lapses on their own create a small increased risk.’’

The problem occurred because new staff members were not trained in the correct cleaning procedure for the scopes, she said. That has now been corrected, and all colonoscopy staffers will be retrained and will have to demonstrate cleaning competency every six months.

The patients involved range from toddlers to teenagers. The hospital’s decision to offer free tests for HIV and hepatitis B and C was made at the recommendation of Public Health — Seattle & King County.

There are no reported cases or reason to believe any of the patients had hepatitis B, C or HIV at the time of their colonoscopies, DiNuzzo said.

The patients are just now beginning to be tested and should someone test positive, DiNuzzo said, the hospital will look into whether outside factors may have played a role.

Immediately after the colonoscopies, there were risks of bacterial infections such as rotavirus or Clostridium difficile, which produce gastric discomfort that would have been treated and cleared up by now, Zerr said.

No infections were reported, she said.

The risks of Infections from the cleaning lapse “is very low,’’ DiNuzzo said. But, she acknowledged, “we don’t know enough about this thing’’ because the data isn’t available.

Last month, Swedish Medical Center advised 27 patients to be tested for HIV and hepatitis after discovering equipment used in prostate procedures was not properly sterilized. A spokesman for that hospital described the risk of infection as “extremely low.”

Material from Seattle Times archives was included in this report. Nancy Bartley: nbartley@seattletimes.com or 206-464-8522



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