The damage from dirty examination scopes won’t stop, with a public health agency in Pasadena, Calif., blasting a respected hospital for failing to report 16 infections that resulted in 11 deaths.
Huntington Hospital may have violated California laws by not informing officials of the outbreak of infections of drug-resistant Pseudomonas aeruginosa. The problems may have surfaced as early as 2013 and ran through 2015. City health inspectors, instead, discovered big problems during a surprise, spot-check of their local hospital last August.
In fact, the institution−the anchor of a large health care system that serves a big swath of suburban Los Angeles−emerges from the inspectors’ report badly sullied, with what is described as a “top to bottom” failure of patient safety procedures.
Huntington staff, for example, knew the scopes−used in gastric examinations−were tough to clean, so much so that they were drying the devices using cans of compressed air from an office supply store, the city health department said in its just-released report. Further, the hospital, when it knew it had three deaths possibly tied to dirty scopes, reported the fatalities−to the manufacturer, not to health officials.
Hospital staff feared they would violate patients’ privacy rights by following state laws, they asserted, and they hoped the scope maker would offer assistance.
As I have written, the scopes’ manufacturer, Olympus Corp. of Japan, has acted in shameful fashion throughout the unfolding scandal. It has paid record fines for kickbacks it paid to hustle its scopes, which, congressional investigators have established, were defectively designed so they could not be thoroughly cleaned of deadly bacteria. Even after hospitals around the world started to report problems to Olympus, it insisted that hospitals were to blame for poor cleaning practices. The maker did not inform individual, complaining institutions that their peers were experiencing similar woes.
Olympus, under pressure from a U.S. Senate investigating committee, finally relented and said it would recall and redesign the scopes.
Pasadena health officials did not delve into the 16 infections, and left unclear how directly linked they may be to the 11 deaths. But, in further proof of the value and necessity of litigation in the civil justice system to cast sunshine in instances of potential wrong-doing, The Times quotes a lawyer saying he is pursuing three cases in which patients died from infections after they were examined using the scopes. He also says the hospital incorrectly has listed causes of death on patient death certificates, failing to note infections and blaming other illnesses.
Huntington officials say they are moving to correct problems, and they say they fully accept the validity of the criticisms from Pasadena health official.
2 other L.A. hospitals under fire
Huntington also isn’t alone among notable Southern California hospitals with infection woes. UCLA and Cedars-Sinai, two of the West Coast’s best-known hospitals and largest academic medical centers in the western United States, both were rebuked recently for infection-control problems. As the Times has reported:
At UCLA Ronald Reagan Medical Center, the state declared an “immediate jeopardy” – meaning lives were at imminent risk – on March 4, 2015, after finding staff using contaminated water and a tainted liquid cleaner dispenser being used to ready colonoscopes and other devices for the next patients. While an “immediate jeopardy” ruling is rare, inspectors used it again 21 days later at an inspection at Cedars-Sinai Medical Center. There they found a “widespread pattern of potential ineffective sterilization and storage of surgical instruments” as well as problems with the disinfection of scopes.
Both hospitals responded swiftly and the state lifted its ruling within hours at UCLA and in a day at Cedars-Sinai. The hospitals disputed the severity of the state action, and said no patients were harmed. Although follow-up state inspections have not found repeated or new issues, experts pointed out that the incidents at such respected institutions underscore the big, constant challenge of infection control in hospitals.
UCLA played a key role in uncovering the dirty scopes scandal, going public after a series of deaths at its flagship Ronald Reagan Medical Center hospital. That prompted an investigation by the Los Angeles Times, which has reported that dozens of patients across the United States were sickened with scope-related infections and at least 21 have died from them.