Device Problems
Device Operates Differently Than Expected (2913); Insufficient Information (3190)
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Patient Problems
Unspecified Infection (1930); No Information (3190)
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Event Date 02/13/2016 |
Event Type
Injury
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Event Description
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Ercp scope was used on a patient with known cre colonization ((b)(6)).The facility followed our routine practice which consists of pre-cleaning and manual cleaning per mfr instruction, utilizing atp testing to validate cleaning effectiveness (rlu well below threshold for action/recleaning), and 2 rounds of high level disinfection in an aer using rapicide peracetic acid solution and meeting all cycle parameters.Ercp scope was used on 2 add'l patients who have not yet presented with any infectious complication.The ercp scope was used on the third patient who returned 18 days later with infectious complications ((b)(6)).Culture revealed that (b)(6) has the same organism, same sensitivity pattern and pfge type match as (b)(6).Gene sequencing of the carbapenemase genes is currently underway.
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Event Description
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Ercp scope was used on a patient with known cre colonization ((b)(6)).The facility followed our routine practice which consists of pre-cleaning and manual cleaning per mfr instruction, utilizing atp testing to validate cleaning effectiveness (rlu well below threshold for action/recleaning), and 2 rounds of high level disinfection in an aer using rapicide peracetic acid solution and meeting all cycle parameters.Ercp scope was used on 2 add'l patients who have not yet presented with any infectious complication.The ercp scope was used on the third patient who returned 18 days later with infectious complications ((b)(6)).Culture revealed that (b)(6) has the same organism, same sensitivity pattern and pfge type match as (b)(6).Gene sequencing of the carbapenemase genes is currently underway.
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Event Description
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Add'l info received from reporter on 05/16/2016 for mw5061659.Updated info: whole genome sequencing indicates that the pts' isolates are closely related.
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Search Alerts/Recalls
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