CONNECTING THE DOTS – ISSUE NO. 382

Being from Detroit, it's hard to read what's going on at a local facility. The most disturbing to me is having worked in the healthcare field for over 40 years, I find this neither new nor surprising. Many of the reports talk about training, competency of staff and resources being made available for improvements in the department. Since the ERCP scope concern, it seems awareness has heightened the focus on departments that do medical device reprocessing. It was only a few years prior that we had the shaver concern, but that seems to be already forgotten. We had a hospital close down in Texas for some time, because of training and not having proper documentation of sterilization records. Or, in 2002 when a hospital in Sacramento, CA had to contact 750 patients because an auxiliary water channel was not cleaned. In another instance, Times Record News in Wichita Falls, Texas reported that a health care system had to inform over 1,800 patients that the instruments used during their surgeries might not have been properly cleaned. The possible source of the concern: the detergent dispenser was not working. Yes, story after story, after story. Myself and a friend - Tracy Humphries - wrote an article on scopes in 2006 called, "Improving the Cleaning Process for Flexible Endoscope" featured in Infection Control Today that warned about scopes not being properly cleaned. Keep in mind that in 2006, no standards body was recommending any type of cleaning verification to be used that would ensure scopes were clean prior to HLD or sterilization. By my unofficial count, over 5,000 patients were told they had to be tested due to a scope reprocessing issue before any recommendation of cleaning verification was issued by professional associations. The dots were there, we just failed to connect them. The Joint Commission released "Most Frequently Identified Root Causes for Sentinel Events, January 1 - December 31, 2015". The first two points were: Human Factors (such as competency assessment and staff supervision) - 999 Leadership (related to issues such as priority setting and complaint resolution) - 849 When you start looking at all of these stories, you begin to see how all of the dots are connected. The issues have been there, but not until it "hits the headlines" does the picture start to form. The dots now start to show the importance of training, competency of the staff performing the tasks correctly, education and certification, as well as resources to provide staff the correct tools they need to perform the tasks accurately each and every time. I've put together a brief PDF, that you can access below, on a few of these dots for your own personal review. I hope you look at it. I wonder what picture you will start to see.