CNN 2010-04-28

Well, we take so many things for granted. Employees will wash their hands before making your food. Police and firefighters will come when you call them and doctors who poke 1 and prod 2 you are using clean instruments. Well, hold off on that last one. One Canadian hospital is warning patients about a potentially deadly problem that went unchecked for nearly two years. Louise Heartland has the outrage 3.

‘The Hepatitis B, Hep C or HIV.’

Those are examples of blood illnesses the Vancouver Island Health Authority says up to 500 patients may have been exposed to after being treated with a tainted 4 piece of surgical 5 equipment. Vic General made the discovery after staff noticed a cloudiness in the cleaning solution. It’s regularly used to sterilize 6 endoscopes, a snake-like diagnostic tool used to examine and detect problems with the liver, pancreas and gall 7 bladder. They found nothing suspicious in regular screenings but after a more details swab test, staff discovered something much more serious.

‘During that process, we discovered some, a small amount of residue 8 in one of the ports on the scope that’s likely to be blood. And that was remaining after the cleaning process was complete.’

Specialized 9 staff cleaned the instruments but the health authority says the scopes need to be soaked right after a procedure but that may not have happened in this case allowing blood to dry.

‘We have changed our process, er, such that there will not be any drying of the instruments that they have to be soaked after use, prior to cleaning. ’

The Health Authority says that it stopped using the equipment after the discovery in February. Days later, a patient returned to the hospital, three days after a procedure with a bacterial 10 infection, linked to the endoscope.

‘He was very ill. The procedure was a palliative measure in his case. And we treated his bacterial infection. He went home. He has subsequently died from his illness, not from the bacterial infection.’

Bacterial infections present within days of procedures. The concern now is viral infections which have a much longer incubation period. Those viral infections include hepatitis and HIV. At-risk patients who underwent procedures with one of the four suspect scopes would have been operated on between June 2008 and January of this year.

‘The risks- I would stress that the risks are very low. And the risks from the literature are around one in 30 million procedures. So we're very unlikely to find any.’

BC’s health minister says it’s unfortunate, but says mistakes do happen.

‘So what you always have to do is be constantly trying to improve performance, have checks in place and make sure you are as careful you can possibly be but you will never eliminate the risk altogether. ’

A sentiment echoed by the Health Authority which warns this could happen again.

‘We cannot say that that’s 100%, that there’s no risk, neither can we say that this cleaning failure was a single event.’