More than 100 surgical patients may have been exposed to viruses.




Failure to follow equipment sterilization guidelines at UPMC Northwest has reportedly resulted in the notification of more than 100 surgical patients who may have been exposed to viruses as varied as hepatitis and Human Immunodeficiency Virus (HIV).

Several reports indicate that an autoclave — hospital equipment that sterilizes surgical and related instruments — was heated at a level not set to ensure infection control.

The improper setting — the heat sterilization period was shortened — was reportedly in place from January through at least July at UPMC Northwest in Seneca.

In that time, some 146 patients undergoing surgical procedures may have been exposed to bacteria as a result of insufficiently sterilized surgical tools.

Those patients were notified by the hospital in a letter dated Sept. 1, 2009, that they may have been exposed to potential viruses. Similar letters went to the patients' surgeons and personal physicians. The letters were signed by Dr. Bridgett Davis, chairman of the hospital's infection control/prevention committee, and Dr. David McCandless, chairman of the hospital's quality improvement committee.

The hospital indicated in those letters that it had "recently discovered" the surgical instruments were "not sterilized to our usual standards" because the heat period was "inadvertently shortened."

That situation could result in potential viral illnesses for those patients whose surgeries were done in the surgical area where the shortened sterilization system was in effect. It is not clear which specific surgical procedures were affected but they are believed to be both out-patient and in-patient surgeries. There is no information, either, on which surgical suite had the autoclave in question.

As a result of the problem, the hospital recommended those patients have their blood tested for up to nine months to determine if they were infected by viruses.

UPMC Northwest issued a press release on the health risk. The hospital statement noted the facility had recently discovered that "a small number of patients who had surgery at the hospital over the past few months may have been exposed to a health risk."

After an investigation, the hospital continued, it was determined "that the risk that any of these patients will experience any health problems as a result of having undergone surgery at the hospital is extremely low."

However, UPMC Northwest urged those patients to accept its offer of "appropriate follow-up laboratory" testing to determine if there has been any infection. The testing follows the guidelines set out by the federal Centers for Disease Control and Prevention.

The testing, which is offered free, begins with initial blood work for liver function, HIV and hepatitis A, B and C. In six months, a patient is directed to have another blood test done for HIV and hepatitis A. In addition, a patient was advised to have monthly blood tests taken for the next nine months to test for liver enzyme and hepatitis B and C.

The prescriptions for the free blood tests were mailed to patients along with the letter advising of the potential surgery-related risks. The tests could be done at UPMC Northwest, Venango Internal Medicine in Oil City, Clarion Family Practice in Clarion, Seneca Commons in Seneca and Pennwood Center in Reno.

The hospital's public statement attempts to assure the public that the health center "is dedicated to providing high quality care to patients and has taken appropriate steps to ensure that the situation will not occur in the future."

In the Davis-McCandless letter to patients, the writers conclude with an apology "for this unfortunate event."

"We are carefully examining our policies and practices to improve our processes to avoid any future occurrences of this type," notes the letter.

Pressed for more details about the incident, UPMC Northwest officials were directed by the parent UPMC corporation in Pittsburgh to refer inquiries there. Calls to the UPMC corporate public relations office for comment were not returned Monday.

The Pennsylvania Department of Health was notified by UPMC Northwest of the equipment problem. A spokesman said Monday that the department has not yet completed a report.

Mother outraged

The parent of a 4-year-old girl who had surgery at UPMC Northwest during that period and who has been advised to have the blood tests is furious about the error.

The Oil City woman, who asked that her name not be used because of privacy concerns for her daughter, said her child had out-patient surgery in mid-July to have ear tubes implanted.

"Then we get this letter on Sept. 3 and my initial reaction was that everything is fine with my daughter because she has not gotten sick," said the young mother. "Then, when I read down and saw all the blood tests she would have to take and it would last for nine months, I thought then that I won't know if everything is okay with her for a long time. It's frightening."

The UPMC Northwest letter to patients lists a telephone number for anyone who has questions about the blood tests or the autoclave mistake. The child's mother called that number and spoke with a female physician.

"She was very, very nice but she wasn't very clear and I felt I was kind of getting a run-around. She assured me that the chances of my daughter being infected are very small and when I said, 'well, what is something comes back positive,' she said she wasn't trying to to downplay my fears but the chances of that are very small," said the woman. "I wasn't really reassured.”

She and her husband have talked with an attorney but the advice was that there is "no case unless something actually comes back positive from the blood tests," she said.

The initial blood tests have been taken, she explained, and described the experience as "traumatic" for her child. The results will go to the family's physician who will then contact the parents. The couple deliberately avoided having the tests done at UPMC or any UPMC-affiliated office, said the mother.

"We went to Seneca Commons so we knew she would be in good hands," she said.

The little girl's mother is pregnant and expecting a baby early next spring.

"My daughter was born at UPMC Northwest when it was brand new and we had no problems at all. I've heard people who have had difficulties there but we have never had any. But we've switched hospitals and I will go for this new baby to Titusville," she said.

Oh My Goodness. I am sick to my stomach! No wonder you are scared! Now I am scared too! I am having a tubal after the birth and I don't want to be touched now! Is there another hospital that you can go to?

Don't listen to the media. They are the ones who cause minor problems to bow up. My auntie and uncle are journalists and i know for a fact they exaggerate to make things seem worse to get headlines. don't panic. keep yourself clean when in hospital and all will be well. xx

As above dont panic a lot of these things are blown out of proportion xxx

Unless you know you're having a c-section it's unlikely that you'll be having surgery anyway isn't it?

Also, they will be mega aware of it now and it'll probably be the cleanest hospital in the USA!

I wouldn't want to read it about the hospital I was meant to be going to, and it's awful that they can get away with substandards for so long, but I'm sure you'll be fine.

It is worrying, and of course if I was one of those people I would be jumping up and down with fury. I would like to think now that scrutiny has come across and they have put something in place to stop this happening again, so I am sure you will be safe.

I have seen some things at my local nhs hospital that I have nearly rang the local paper about, but instead went direct to the top Chief Executive office and reported it. x

Ignorance is bliss!! I am starting to believe that one

theres a hospital 20 miles away im considering.

the hospital was talking on yesterdays news and confirmed it.im just gonna go to another hospital.better safe than sorry