About 2,700 former patients of the High Prairie Health Complex in High Prairie, Alta., may be tested for infection after officials discovered that syringes may have been used on multiple patients to administer medication through IV lines.
"Syringes were reused for endoscopies and in the recovery room of the dental surgery," Dr. Albert de Villiers, the medical officer of health for Alberta Health Services-Peace Country Health, said Monday.
The reuse of the syringes created the potential for backflow on the IV lines, where fluid from a line could be drawn back into the medication.
"If the remaining medication was then used on another patient, there's a potential for transmission of infection," de Villiers said, adding a risk assessment has revealed little chance of infection.
"The risk of backflow and transmission is very low, and we want to stress the point that it is very low," he said.
The problem was identified in early October when a new staff member at the hospital was being shown the process of administering medication to patients.
"A manager, basically supervising the process, caught it," he said.
Tests will check for HIV, hepatitis B and C
Alberta Health Services will be contacting patients by phone and registered mail for followup blood testing. Patients will be tested for HIV and hepatitis B and C.
Interviews with staff revealed the reuse of syringes may have occurred during roughly 1,300 endoscopy procedures between March 1, 2004, and Oct. 2, 2008.
Everyone who had the endoscopy treatments during this time will be offered testing.
Dental surgery patients who received medication through IV lines prior to Oct. 2, 2008, may also be at risk.
Health officials are reviewing patient charts to determine who needs to be tested.
This review will go back to 1990 and could potentially involve another 1,400 patients, but de Villiers said not everyone who had dental surgery at the health centre during this time will need to be tested.
'Mistakes … will be made': health minister
"We have a health system that is made up of hundreds of thousands of very dedicated employees. They're all human beings .… There will be mistakes that will be made," Alberta Health Minister Ron Liepert said Monday.
Liepert said the Health Quality Council of Alberta will investigate, but he refused to speculate on who is responsible, saying laying blame could get in the way of finding out what happened.
"As soon as we start to point fingers and try and point blame, people are going to tend to not want to co-operate," he said.
"What we want to ensure is that when the review is being undertaken … we want to leave with all participants in that review the feeling that they can be honest, be open about process that was occurring, because if we don't do that, we are not going to get to the root cause and it could very well flare up somewhere else," he said.
Alberta's acting chief medical officer of health, Dr. Gerry Predy, said he doesn't believe that the practice of reusing syringes for IV lines exists in other hospitals in the province, but he has sent a memo to all the medical officers of health to make sure.
"We have not heard back that it is happening anywhere else at this point," he said.
In March 2007, St. Joseph's Hospital in Vegreville, east of Edmonton, was closed for several weeks following the discovery of a superbug and the use of improper sterilization techniques for medical equipment.
Thousands of patients had to be tested for infection.
About 1,300 former endoscopy patients could be affected, not 13,000, as was originally reported.Oct 27, 2008 10:18 AM MT