Page 1971 - Week 07 - Thursday, 23 August 2007
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2006 ACT Health conducted a lookback exercise of patients who had undergone a paediatric rectal suction biopsy at Canberra hospital in the years between 1987 and mid-October 2006. The decision to take this action was made when it became apparent that two of the four paediatric rectal suction biopsy tools used by Canberra hospital over the period of time had been cleaned but not sterilised in accordance with current Australian sterilisation standards, potentially putting at risk of infection any children who had had biopsies taken using these tools.
The lookback exercise contacted all children and their families who had received biopsies from these tools to explain what had happened and to undertake testing to assess whether or not they had contracted any infections as a result. The lookback exercise is now complete and there is no evidence that any of the children were infected as a result of using the tools.
This incident did, however, identify a problem with the processes for tracking and sterilising equipment at Canberra hospital, and an internal review commenced immediately to identify how and why these tools had not been appropriately sterilised over a 19-year period. To complement the internal review, an external review into reusable medical and surgical devices at Canberra hospital commenced in March 2007. The objective of the external review was to examine the systems and processes at Canberra hospital for the identification, tracking, recording and reprocessing of reusable instruments, devices and equipment to ensure compliance with the Australian sterilisation standards.
The successful tenderer for this review was SpencerSmith and Associates. The report tabled in the Assembly today documents the interim report of the review outlining the findings and recommendations of this first part. The interim report identifies that appropriate actions have been undertaken and are underway to improve processes associated with sterilising the surgical equipment at Canberra hospital that will reduce the chance of similar problems occurring in the future.
However, the report also identified a number of areas where work can be built on to improve the sterilising process. These fall into four broad categories. They are: improving governance structures involving ACT Health sterilising services, Canberra hospital infection control, Canberra hospital operating rooms and Calvary public hospital; enhancing the tracking systems and processes across ACT Health for surgical equipment to ensure that there is a comprehensive electronic tracking of all reusable instrumentation within Canberra hospital and Calvary hospital; the commissioning of an audit of sterilising services and putting in place measures to ensure that the sterilising facilities at Canberra hospital have the capacity to meet the demands placed on them.
The interim report includes 11 recommendations to address these issues, and an action plan in response to these recommendations has been developed by ACT Health and is currently being implemented. Before describing some elements of the extensive work underway, I would like to reassure members and the ACT community that, while the incident that led to this review should never have happened, overall sterilising and infection control services at the Canberra hospital are of a high standard.
In May 2007, ACT Health sterilisation services was fully accredited by an independent accreditation agency against the relevant standards. What this
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