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Dirty surgical equipment at UC San Diego hospital sparked serious state response

Posted: 7:30 PM, Jun 07, 2018
Updated: 2018-06-13 20:41:23Z
SAN DIEGO (KGTV) - UC San Diego Health is addressing California health department concerns over cleaning issues with its surgical equipment. The problem was serious enough for the state to declare “Immediate Jeopardy” at the hospital, UC San Diego’s Hillcrest campus.
 
“Immediate Jeopardy” is assigned when a hospital's errors have caused or are likely to cause serious injury or death to the patient. The deficiency was found in the way the hospital was washing instruments for surgeries.
 
It was discovered during a routine compliance check conducted by the California Department of Public Health in March. Officials noted that “surgical instruments were not cleaned and processed according to nationally recognized infection control standards".
 
The report declares that the hospital “failed to ensure they had an effective, active system wide infection control program…”. Deficiencies that were found included trays with surgical equipment that had brown staining. Sterilizing machines reportedly had large amounts of dark rust color and the exteriors were covered with dirt. In a post-operative room, instruments apparently had red stains. The report reads that a supervisor said, "If there is still blood on the instruments, someone did not spray as much…".
 
UC San Diego Health sent 10News the statement below on Thursday.
 
“UC San Diego Health recently underwent a routine survey with the California Department of Public Health (CDPH). Opportunities for improvement were identified within an early phase of instrument cleaning that occurs before the actual sterilization. Immediate actions were taken.
In an abundance of caution, UC San Diego Health chose to reprocess (clean, decontaminate and sterilize) all surgical instruments. CDPH approved this comprehensive approach.
UC San Diego Health conducted a review of surgical data before, during and after the survey.
This review found no infections related to cleaning and sterilization processes. There has been no evidence of patient impact or harm.
UC San Diego Health also wrote:
"We understand that you might have concerns or questions. UC San Diego Health's Patient Experience Team has extended their hours tonight to take your calls. You may contact them at 619-543-5678.  Or you can email  welisten@ucsd.edu ."
 
“Immediate Jeopardy” was lifted about 24 hours after it began.
 
The hospital said that patients didn't need to be notified and surgeries were not canceled. 10News confirmed with state officials that the hospital wasn't required to notify patients or suspend surgeries.
 
10News has learned that there have been at least seven other times since 2007 that the hospital went into “Immediate Jeopardy”, according to a December press release from the CA Department of Public Health. One case involved a patient who died after staff reportedly failed to notice he had flatlined. The hospital was fined $44,000.

[Editor's Note: This article was edited to include information provided by UCSD and CDPH after the original story was published.]