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http://www.canada.com/national/story.asp?id=EA29E215-AF25-41CB-B658-B76C8E2A409F
Toronto hospital issues HIV warning after unsterilized testing
Biopsy probe unsterilized: Ontario orders all hospitals to review infection control
Allan Woods
National Post
ORONTO - Sunnybrook hospital yesterday warned about 860 men that they were tested for prostate cancer with an unsterilized biopsy probe, potentially exposing them to HIV and hepatitis B and C.
Hospital officials blamed complex manufacturer's instructions for a tool used to take prostate gland tissue samples.
Men who underwent the procedure between December, 1999, and August, 2003, received letters yesterday from the hospital offering blood testing at home, at work or at the hospital.
But Sunnybrook officials fear that if such a safety breach occurred at their hospital, it has likely happened elsewhere. It warned other Canadian hospitals to review their procedures.
"Our concern is that this is much more widespread," said Dr. Andrew Simor, head of microbiology at the hospital. "Our concern is that this is the tip of the iceberg."
The revelation comes more than three months after the hospital completed an internal audit to identify areas where infection control measures were not being followed. Hospital staff have been working since then to identify patients at risk.
While this was the only breach identified by the audit, the hospital admitted it had not been sterilizing the half-dozen tools since Sunnybrook first started using them in December, 1999.
"It was not meeting the current standards since it was first introduced," Dr. Simor said.
"The people using the equipment did not understand [the instructions] and even I, looking at it now, can see why it would be easy to misinterpret."
The long thin probe is covered in a rubber sheath and inserted in the rectum. A small needle is inserted into the prostate to collect a tissue sample that can be tested for cancer cells. The potential exposure occurred where the needle pierces the rubber sheath, said Dr. Bob Lester, Sunnybrook's vice-president of medical and academic affairs.
The manufacturer, BK Medical of Wilmington, Mass., did not return phone calls to defend allegations that its instructions were too complex.
This is the second incident involving unsterilized medical equipment in Ontario's hospitals in the last three weeks. A hospital in Oshawa, just east of Toronto, is facing two lawsuits totalling $81-million after throat and colon scopes were cleaned but not disinfected.
Sunnybrook's president and chief executive, Leo Steven, would only emphasize the low risk of infection -- one in 100,000 -- when asked if he was bracing for a similar lawsuit.
However, a lawyer working on the lawsuits against the Oshawa hospital said a class-action claim by some or all of the 861 men treated at Sunnybrook is almost a certainty.
"I heard about it on the radio today and it sounds frighteningly similar," said lawyer Kevin Mitchell-Gill. "With the period of time that has passed [since 1999] there is a significant chance of cross-contamination of spouses and loved ones. [These men] will have to go through a period of their lives taking precautions that a potentially infected person would have to take."
In an attempt to prevent any similar incidents, George Smitherman, the Ontario Health Minister, has ordered every hospital in the province to conduct a thorough infection control audit and report back by Jan. 9, 2004.
A health ministry spokeswoman would not say if those results will be made public or how the province will deal with poor results.
Dr. Peter Norton, a physician from the University of Calgary who specializes in patient safety, said the recent discoveries underscore the necessity of a National Patient Safety Institute, which received federal funding this year to monitor and prevent incidents of medical error.
The institute, which is not yet established, will cost an estimated $50-million over five years.
Toronto hospital issues HIV warning after unsterilized testing
Biopsy probe unsterilized: Ontario orders all hospitals to review infection control
Allan Woods
National Post
ORONTO - Sunnybrook hospital yesterday warned about 860 men that they were tested for prostate cancer with an unsterilized biopsy probe, potentially exposing them to HIV and hepatitis B and C.
Hospital officials blamed complex manufacturer's instructions for a tool used to take prostate gland tissue samples.
Men who underwent the procedure between December, 1999, and August, 2003, received letters yesterday from the hospital offering blood testing at home, at work or at the hospital.
But Sunnybrook officials fear that if such a safety breach occurred at their hospital, it has likely happened elsewhere. It warned other Canadian hospitals to review their procedures.
"Our concern is that this is much more widespread," said Dr. Andrew Simor, head of microbiology at the hospital. "Our concern is that this is the tip of the iceberg."
The revelation comes more than three months after the hospital completed an internal audit to identify areas where infection control measures were not being followed. Hospital staff have been working since then to identify patients at risk.
While this was the only breach identified by the audit, the hospital admitted it had not been sterilizing the half-dozen tools since Sunnybrook first started using them in December, 1999.
"It was not meeting the current standards since it was first introduced," Dr. Simor said.
"The people using the equipment did not understand [the instructions] and even I, looking at it now, can see why it would be easy to misinterpret."
The long thin probe is covered in a rubber sheath and inserted in the rectum. A small needle is inserted into the prostate to collect a tissue sample that can be tested for cancer cells. The potential exposure occurred where the needle pierces the rubber sheath, said Dr. Bob Lester, Sunnybrook's vice-president of medical and academic affairs.
The manufacturer, BK Medical of Wilmington, Mass., did not return phone calls to defend allegations that its instructions were too complex.
This is the second incident involving unsterilized medical equipment in Ontario's hospitals in the last three weeks. A hospital in Oshawa, just east of Toronto, is facing two lawsuits totalling $81-million after throat and colon scopes were cleaned but not disinfected.
Sunnybrook's president and chief executive, Leo Steven, would only emphasize the low risk of infection -- one in 100,000 -- when asked if he was bracing for a similar lawsuit.
However, a lawyer working on the lawsuits against the Oshawa hospital said a class-action claim by some or all of the 861 men treated at Sunnybrook is almost a certainty.
"I heard about it on the radio today and it sounds frighteningly similar," said lawyer Kevin Mitchell-Gill. "With the period of time that has passed [since 1999] there is a significant chance of cross-contamination of spouses and loved ones. [These men] will have to go through a period of their lives taking precautions that a potentially infected person would have to take."
In an attempt to prevent any similar incidents, George Smitherman, the Ontario Health Minister, has ordered every hospital in the province to conduct a thorough infection control audit and report back by Jan. 9, 2004.
A health ministry spokeswoman would not say if those results will be made public or how the province will deal with poor results.
Dr. Peter Norton, a physician from the University of Calgary who specializes in patient safety, said the recent discoveries underscore the necessity of a National Patient Safety Institute, which received federal funding this year to monitor and prevent incidents of medical error.
The institute, which is not yet established, will cost an estimated $50-million over five years.
