An investigation at Carilion Roanoke (Va.) Memorial Hospital revealed sterilization issues with surgical equipment that reportedly occurred between March and September 2023, Cardinal News reported March 4.
The hospital initially received an immediate jeopardy citation by CMS, but has since received approval on its action plan to address the issues by the Virginia Department of Health.
The unsterile tools were not ever used on patients, but the sterilization issues did lead to a handful of surgeries being rescheduled or transferred to another location in August, according to Cardinal News.
An anonymous complaint to the Virginia Department of Health stated that on several occasions surgical instruments at the hospital were reportedly turning up in operating rooms with marks, blemishes and in one instance, tools even had pieces of alcohol pads and sutures stuck to them, Cardinal News reported.
The hospital received a C on Leapfrog Group's most recent health safety grade reports, but in December it was recognized as a top performing hospital in the U.S. for maternity care.
"We knew there would be interest in this work and the lessons learned of our Sterile Processing and Carilion Roanoke Memorial Hospital, which is why we wanted to offer a transparent look through recent coverage," a Carilion Clinic spokesperson told Becker's. "The surveys centered on an uptick in hard water blemishes on sterilized surgical instruments. While blemishes from hard water are an everyday occurrence across the industry, we saw an uptick last summer, resulting in a higher than normal rate of instrument rejection. This was a complex issue that required an interdisciplinary team of experts to address. Above all, it’s critical to note that our patient safety processes worked. We identified and removed instruments of concern prior to procedures; they were not used in patient care."
The spokesperson also noted that since this occurred, other measures have also been implemented to prevent sterilization issues in the future including assigning additional training for staff in the OR and its central sterile staff, made workflow improvements to avoid human error as much as possible, and has implemented regular audits of trays of the surgical instruments prior to use.