The Colorado Department of Public Health and Environment completed its investigation into Denver-based Porter Adventist Hospital April 17. In its report, the CDPHE found the hospital failed to adequately sterilize surgical instruments, some of which were found to have chunks of bone, blood, dead bugs, hair and cement, among other contaminants, according to ABC 7 Denver.
The department initiated an investigation into the hospital Feb. 22 after becoming aware of the infection control lapse one day prior.
On April 4, the hospital notified approximately 5,800 orthopedic and spine surgery patients who received care at the hospital between July 21, 2016, and Feb. 20, 2018, that they may be at risk for surgical site infections or exposure to hepatitis B, hepatitis C or HIV due to inadequate sterilization practices. The hospital suspended surgeries scheduled to take place April 5 and April 6 after DOH officials began their investigation. Porter Adventist resumed surgeries "on a limited schedule" April 12.
Hospital officials determined April 14 the infection control lapse resulted from a human error.
The DOH investigation found 76 instances of contaminated surgical instruments and trays being used at the hospital between Jan. 1, 2017, and April 2, 2018. The probe also found that because the instruments were not properly sterilized, surgeries at the hospital were delayed or in some cases interrupted, according to ABC 7 Denver.
The department probe also noted Porter Adventist failed to report some infections stemming from the infection control lapse to the CDC's National Healthcare Safety Network.
The CDPHE approved the hospital's plan of correction and said it would conduct an unannounced site visit to ensure the issues are resolved. The department is also reportedly determining whether to issue sanctions against any of the hospital's licenses, according to the report.
To access the full report, click here.
In a June 14 statement to Becker's Hospital Review, a Porter Adventist Hospital spokesperson said: "Patient safety remains our number one concern at Porter Adventist Hospital and we continue to work collaboratively with CDPHE to ensure best practices at our hospital."
Editor's note: This article was updated June 14 at 3 p.m. to include additional information from Porter Adventist Hospital.