Bone Fragment on Surgical Tool Alerted Officials to Possible Sterilization Breach at Porter Adventist Hospital
15 April 2018 | The first clue that there may have been a problem with the cleaning of surgical instruments at Porter Adventist Hospital in Denver, Colorado, came last April when a doctor found a bone fragment from a past surgery stuck to a tool.
The Denver Post reported that the doctor was in the middle of a surgery when he discovered the compromised tool on a tray.
The discovery was not made public until a year later. The hospital sent letters to approximately 5,800 patients who had received orthopedic or spinal surgeries at the hospital between July 21, 2016 and April 5, 2018, notifying them that they had been exposed to potential infection due to a problem with the sterilization process of various surgical instruments.
The Denver Post reported that the patient notification took place two months after external inspectors from a national hospital accreditation organization spoke to Porter administrators about the problems with their cleaning process.
The hospital’s CEO, Morre Dean who is also president of parent system Centura Health’s South Denver Hospital Group, told The Denver Post that the delay in notifying patients was due to the time needed for information gathering and because there was no sign of an abnormally high infection rate.
For almost a week starting Friday, April 6, surgeries were suspended at Porter due to a residue found on some surgical instruments that was deemed to be the result of a water quality issue. Surgeries restarted at the hospital on a limited schedule on Thursday, April 12.
The Colorado Health Department stated on April 11 that it had discovered a number of patients with surgery-related infections from the period but could not tie them to irregularities in the cleaning process. No infections by viruses such as hepatitis B, hepatitis C or HIV have been found.
Porter Adventist Hospital is a 368-bed acute care hospital in the University of Denver area of Denver, Colorado. It is part of Centura Health, a health system managed under a joint operating agreement formed in 2006 between Adventist Health System and Catholic Health Initiatives. Centura operates facilities in Colorado and Kansas.
