Sterilisation slip put six at risk

Failures to sterilise surgical instruments put six hospital patients in Auckland at risk of infectious diseases.

The management at Auckland City Hospital blames an employee of its sterile supply service.

Last year the Herald revealed that when the hospital's surgeons reached for instruments, they sometimes found they were missing or contaminated with human flesh - albeit sterilised - from a previous patient.

The ongoing problems in the $10 million sterile supply service - which centralised previously dispersed units when it opened with the new hospital in October 2003 - contribute to longer waits for elective surgery, by slowing down operations while fresh instruments are obtained.

The management said the instruments posed no infection risk and the infection rate was lower than in the three hospitals the new facility replaced by last October.

General manager Nigel Murray said yesterday that all of the six patients, including the mother of a child who had dental treatment at Starship, had been told of the lapses and were offered appropriate support.

The risk of the patients developing an infection due to the unsterilised instruments was tiny and none had.

When asked whether the person responsible for the lapses had been sacked or otherwise disciplined, Dr Murray said legal reasons prevented his answering fully. "Appropriate HR [human resources] processes have been completed."

He said the person had failed to sterilise two batches of instruments - containing several hundred items - in high-temperature steam sterilisers in November and January.

Computer records and the absence of a required signature on forms showed the batches had not gone through a steriliser. However, both batches were fully washed, cleaned, and decontaminated to 90C with disinfectant chemicals.

The non-sterilisation of the instruments should have been picked up by other staff handling the instrument packs, Dr Murray said. The packaging, which goes through the sterilisers with the instruments inside, has heat sensitive indicator dots which change colour during the cycle.

The general manager of clinical specialty services, Fiona Ritsma, said that in the child's case, the instrument was a hand-held clamp used to tighten a band around a tooth being filled. It did not need to be sterilised, but the board's policy was that such instruments should be sterilised anyway.

Provisional figures in yesterday's Auckland District Health Board meeting papers suggest that last June 12.4 per cent of operations involved a reported sterile supply incident - ranging from a missing instrument to inadequate cleaning - reducing to 5.8 per cent in January.

That was still too high, said elected board member Chris Chambers, an anaesthetist. "This is twice the international standard in effect."

Dr Murray said the statistics were incorrect. He "conservatively" estimated January's rate as 4.2 per cent and said the international benchmark was 3 to 5 per cent. "We'll be pretty close to where we want to be in six to eight months".

Ian Powell, executive director of the senior doctors' union, blames the problems on inadequate resources.