160 local residents are among 3,400 notified of possible medical equipment contamination
About 160 Ramona-area residents have been notified that they could have been exposed to infections during medical procedures at a number of Palomar Pomerado Health (PPH) departments from Dec. 1, 2008 to March 22, 2010.
Certified letters were mailed early last month to a total of 3,400 patients in the county who were informed that techniques used to disinfect equipment during a 16-month period could have put them at risk for hepatitis B, hepatitis C or HIV. Patients were directed to contact a call center, staffed by registered nurses, and set up an appointment for a free blood test.
As of last Friday, 1,112 patients had been tested and not a single infection has been found, said Opal Reinbold, chief quality officer for PPH.
“We knew that the risk was very low, but we just took this extra step because we did not want to take any chances. Consideration for our patients comes first,” Reinbold said.
She explained that the questionable practices dated back to December 2008, when the Center for Disease Control tightened the requirements for disinfecting medical instruments used in diagnostic procedures. This past March it was discovered that some PPH staff members had reverted to following the old guidelines.
“Semi-critical instruments are cleaned between every use in a special solution and that solution is tested with a test strip before every use to be sure that it is still efficacious,” Reinbold said. “But we found a couple instances where the solution was not discarded after 14 days, as required, but after 16 days.
“We also found some areas that were not keeping accurate logs so we could not follow every step and document it.
“We immediately notified the state, even though no harm had come to any patient, and made the decision to notify the patients even though this was not something that we had to do.
“Now we have centralized the process so it is easier to audit, and retrained staff members.”
After the affected patients receive their free blood test, they are mailed the results. And if they are still in the time frame for contacting an infection, they will be instructed to return for another test.
“We have a complete spreadsheet on every patient so we can track the results,” Reinbold said. “And the blood tests are being sent to an outside lab so patients can be assured that there is an objective look at the results.”
Reinbold did not know how many of the 160 Ramona residents have contacted the call center. But she said that two attempts will be made by phone to reach those who have not responded, and it’s possible that some of those patients may have talked to their doctors and decided not to take the test.
One Ramona resident who received the letter is a female attorney with a background in medical malpractice cases. She did not wish to be identified because of the personal health concerns involved, but she said that it “really got my attention” that the letter was signed by PPH’s chief executive officer, Michael H. Covert.
“I thought it was unusual for the letter to come from the CEO and it made me more concerned,” she said. “I feel fine. I’m eating, taking my vitamins and trying to stay healthy, but I’ll feel better after I get my blood test next week.”
Putting on her attorney’s hat, she said that PPH “is taking the appropriate approach and I commend them on that.”
However, as a patient, she said, “One of the things that alarmed me so much is that cleaning and disinfecting seems to be a standard procedure. Why did it take so long to discover that there was a problem?”