Louisiana: Hospital Warns 360 Patients of Error

Tulane Medical Center has sent letters to inform 360 patients that improperly sanitized medical equipment may have put them at risk for diseases. While the infection risk is "minimal to non-existent," TMC is offering free screening for hepatitis B, hepatitis C, and HIV "to reassure patients whose procedures were impacted," said Dr. Robert Lynch, the New Orleans hospital's CEO.

According to his Jan. 3 letter to patients and a TMC statement released March 10, a routine maintenance inspection found bronchoscopes and endoscopes were not disinfected at sufficiently high temperatures. From Oct. 7 to Dec. 1, the error affected colonoscopies, sigmoidoscopies, and upper-endoscopies.

"Once this was discovered, it was remedied immediately," Lynch wrote, and TMC contacted infection control experts, including the Louisiana Department of Health. The transmission risk "would be extremely, extremely small," said DPH's Dr. Raoult Ratard, an epidemiologist who has consulted TMC. "I think Tulane just wants to be careful."

The risk of endoscope-associated infection is about one in 1.8 million procedures, according to CDC. However, endoscopes are the medical devices most likely to be linked to outbreaks associated with health care institutions.

The scopes implicated cannot be steam-sanitized because of the risk of heat damage, said Ratard. A chemical disinfectant or sterilant instead is used on the equipment for a specified period of time and at an elevated temperature. Due to human error, the temperature setting on TMC's sanitizer was too low, a "fairly common" problem for health providers across the nation, he said.

Efforts to notify patients and offer several rounds of testing and follow-up counseling show that TMC "has handled this by the book," Ratard said.

One affected patient has already filed suit in Orleans Parish Civil District Court, accusing TMC of negligence and asking for class-action status. TMC is jointly owned by the for-profit Health Care Corporation of America and Tulane University.