There have been five breaches of standards after surgical instruments were not properly sterilised in five operations at Dunedin Hospital over a period of almost a year, it's been revealed.
The five standards breaches, which took place between March 31, 2020 and January 31, 2021, include three involving surgical cement; one involving hair; and one involving water in a connector found on or within the instruments or instrument tray once a procedure had started in theatre, Southern DHB chief executive Chris Fleming said today in a statement.
He said in the first four cases the material and/or instruments were removed and replaced before being used on the patient.
"However, because the theatre event had commenced, these incidents breach the high standards we have set ourselves and we report this as a transgression. There is a risk that even if the instruments have not been used directly on a patient, they may have come into contact with other instruments that had been used, thereby compromising the sterile status of the other equipment," he said.
"There are also concerns that they could represent wider problems with the specific pack being used that had not been identified."
He added, however, that the contaminants had been through the sterilisation process so "the risk of them containing any infectious material is extremely low".
Fleming said a process has been established for managing these situations, and the DHB is now working to ensure it is consistently implemented.
"All events were reviewed, and opportunities for improvement identified. There were no adverse outcomes to the patients as a result of these breaches.
"We acknowledge that any event is too many and we continue to focus on improving our processes and thank our teams for their efforts in this."
Fleming said the DHB Sterile Services Team "take these five identified breaches extremely seriously".
"Sterilisation is of paramount importance to the work of any hospital, and at Southern we have highly dedicated Sterile Services and Theatre teams. This work is particularly challenging for the Sterile Services team in Dunedin, who work in a cramped space that is not fit for purpose."
A new facility is being developed in Dunedin, which is expected to be completed next year.
Fleming said "significant work" has been carried out in the interim to "tighten processes and monitoring to mitigate the risks created by the facility constraints," such as "additional staffing, including a dedicated education and quality resource, and implementing additional steps to ensure greater checking and monitoring".
It follows a similar incident in which up to 55 people were affected by a batch of equipment that was not properly sterilised in the Hawke's Bay in 2019.
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