A facility reported that intercept detergent was accidentally added to the alcohol bottle used in their advantage plus automated endoscope reprocessor (aer).It was reported that five endoscopes were reprocessed and used in patient procedures after intercept detergent was added to the alcohol bottle; thus, there is potential that patients were exposed to intercept detergent during procedures.During the alcohol purge phase of the reprocessing cycle in the advantage plus aer, alcohol is injected through the endoscope channels to help purge any residual fluids from the endoscope.It is unknown how much detergent was added to the alcohol bottle.Medivators provided the facility with the intercept detergent safety data sheet (sds).Medivators technical services provided the facility assistance with cleaning out their aer and returning the unit to service after the incident.It is stated in the advantage plus aer user manual, "to prevent the accidental switching of the alcohol and detergent reservoirs, always remove, refill and replace each reservoir bottle separately.Refilling the container with the incorrect fluid may cause the endoscope to be improperly disinfected.Do not use the endoscope on a patient if this occurs." therefore, the facility did not follow the instructions from the user manual.Medivators regulatory followed up with the facility and they reported no patient adverse reactions and no additional medical attention was sought by the five potentially affected patients.This complaint will continue being monitored in medivators complaint handling system.
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