Wyoming Agency Says Patients Have Right to Know About Unsterile Surgical Tools

February 28, 2017

A hospital in Lander, Wyo., should inform patients who had surgery between December 2013 and October 2016 that they could have been exposed to non-sterile surgical instruments, the state health department said.

Officials with the Wyoming Department of Health say surgeons at SageWest Healthcare on several occasions found dried blood and “bone-like fragments” on instruments that were supposed to be sterile, the Casper Star-Tribune reported. The health department investigated the hospital four times over the past three years for failing to properly sterilize instruments.

In October, the state wrote a letter to the hospital saying it was considering recommending the federal government stop paying for Medicare and Medicaid treatment at the hospital.

State Survey Agency Director Laura Hudspeth gave the hospital a week to submit an acceptable correction plan. The plan was accepted in November.

While the risk of infection is low, patients should still be informed they may have been placed at risk for hepatitis B, hepatitis C or human immunodeficiency virus (HIV) and they should be offered free blood tests, Health Department spokeswoman Kim Deti said.

SageWest spokeswoman Lindsey Anderson issued a statement saying the hospital purchased new equipment and implemented cleaning procedures that “go dramatically above and beyond even the highest requirements from the federal government.”

“Importantly, there is no evidence of any patient harm or infectious disease transmission to any surgical patient at SageWest Lander,” Anderson said in an email.

Deti said the agency’s Public Health Division dos not have the regulatory authority to sanction SageWest if it does not notify patients or offer the blood tests.

Department of Health Director Thomas Forslund wrote a letter to the Wyoming Board of Medicine on Dec. 21 recommending the patient notification. The Star-Tribune obtained a copy of that latter last week.

Anderson declined to say whether SageWest had contacted patients potentially exposed to unclean surgical tools, whether it would do so or how many surgical patients were treated at the hospital between December 2013 and October 2016.

The health department’s October report said SageWest’s Lander hospital “failed to complete the cleaning, inspection and sterilization process necessary to ensure surgical instruments were free from potential infectious materials.”

In July, “bone-like fragments” were found on a surgical tool in the operating room before a procedure. In September, a surgeon tried to place a suction device into a patient’s throat but it malfunctioned because of “dried blood materials” on the instrument.

The first safety violation was found in 2014, when a surgeon said sometimes instruments used in operations were not washed and sterilized for one or more days, making it more difficult to remove dried substances. A report noted the hospital was not complying with the federal infection control program standards.

In June 2015, another report said the hospital had failed to address the issue. Last spring, a third report found that operating rooms did not meet federal standards for sanitation and staff were not properly cleaning the blades and handles of laryngoscopes, which are used to examine the throat.

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