Porter Adventist Hospital infection breach caused by human error

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DENVER -- Porter Adventist Hospital executives admitted Thursday the infection breach that could have affected 5,800 orthopedic and spine surgery patients was caused by human error.

Chief medical officer Dr. Patty Howell and Centura Health senior vice president Morre Dean apologized for the breach and explained how it happened.

They refused to say how many patients have been infected.

Orthopedic and spine surgery tools go through a multistep cleaning process, including a mechanical cleaning and heat sterilization.

Howell and Dean said those processes were never affected.

But before those processes, the surgical tools undergo a pre-cleaning. This is where hospital staff soak and scrub the tools.

Howell and Dean said the breach comes from the tools not being cleaned properly and potentially containing bioburden -- pieces of bone, tissue, etc.

"They’re wiping down with towels, they’re soaking in bins and specific to orthopedic and spine instruments," Howell said. "Those instruments tend to be highly complex.

"There’s a lot of nooks and crannies, sharp areas, mechanisms, that exist in those. Staff was doing cleaning, but they felt there should be more cleaning."

Porter was informed of the breach on Feb. 20 when the Joint Commission, a hospital accreditation agency, visited the hospital.

Howell and Dean said the cleaning process was fixed that same day. Officials waited six weeks to tell patients and eventually suspend surgeries.

"When the Joint Commission first identified the issue, it was not identified as an issue that caused patient harm," Dean said. "Part of the reason we extended the notification period of patients was continued feedback on our process from CDPHE that we’re still not to the place we feel like we’re perfect. And we might as well include those people."

During that time, Porter also realized it had a problem with a cleaner that would leave mineral deposits on surgical tools. Dean and Howell said that's been fixed, as well as the cleaning issue.

Surgeries are now continuing at Porter Adventist, but on a limited schedule.

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