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Hospital Sends Letters to 3,400 Patients About Possible Endoscopic Equipment Contamination

Cheryl Clark, for HealthLeaders Media, June 16, 2010

A Southern California hospital says it has sent certified letters to 3,400 patients treated since Dec. 1, 2008 suggesting that they should consider returning for free tests for infection because endoscopic equipment used in their care may not have been properly disinfected.

"The 3,400 patients were identified and each received a certified letter," says Andy Hoang, spokesman for Palomar Pomerado Health System, a public hospital district based in Escondido and Poway. 

The care was provided at PPH’s 319-bed Palomar Medical Center in Escondido, 107-bed Pomerado Hospital in Poway, and its Escondido Surgery Center, an outpatient surgery facility in San Diego County.

"We have a call center set up and are actively accepting calls and making follow-up appointments for all of our interested patients," Hoang says. Patients receiving the letters had received care between Dec. 1, 2008 and March 22, 2010, he says.

Hoang declined to say what procedures involved improperly disinfected equipment, or what that equipment was, except to say that it was a "variation in the cleaning of the equipment" used, and that it was for endoscopic use.

"Although we were disinfecting all equipment, some of the steps as recommended by the manufacture were not always completed," he says.

Hoang says the potential for infection is very low, or "anywhere from 1 in 40,000 to 1 in 500,000" depending on the type of virus or bacteria that might have been transmitted.

He emphasizes that initially, the hospital determined that only 30 patients may have been exposed and that they had been seen in the hospitals during a shorter window of time.

But "we made the decision to make a broad disclosure to go back at least 16 months—this is a precautionary measure. We don't want to take any chances, so we took the extra measure to notify all patients that might be affected—3,400."

As required by state law, the episode was reported to officials with the California Department of Public Health.

Hoang says the hospital will not release a copy of the letter template sent to the patients because the letter is between the hospital and the patient and contains medical information, the release of which would violate the Health Insurance Portability and Accountability Act.

No patients have been determined to have become infected as a result of the procedures, and no such reports prompted the review, he says. Rather, he says, the issue was discovered during the system’s routine oversight process. "It was not prompted by any indication of an increase in infections or a complaint or investigation by the state."

He adds, "nothing like this has happened before."

Since the discovery, Hoang says, "We have done a complete review of all of our procedures related to the cleaning process, retrained all staff, and have mechanisms in place to assure this has been addressed. Appropriate follow-up with staff has been done."


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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