Look back exercise following a failure in sigmoidoscope decontamination
PHE ePoster Library. Johnson A. Apr 10, 2019; 259606; 15574
Dr. Alison Johnson
Dr. Alison Johnson
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Abstract Introduction

- In September 2018, it was identified that the Trust had not fully implemented the MDA alert issued in 2010 with regard to decontamination of rigid sigmoidoscopes. The filter had not been changed between patients and parts of the scope had not been adequately cleaned. An incident meeting was held and it was agreed that as well as a change in practice, a look back should be undertaken to identify whether any patients had been exposed to blood borne viruses


- Patients with blood borne viruses were identified from the laboratory information management system and from sexual health service records. Demographic details were matched with the Trust patient administration system to determine whether any of these patients had been seen in the relevant colorectal clinic. Patient notes were examined to determine whether a sigmoidoscopy examination had been undertaken and the clinic list and timings reviewed to determine whether any patients had sigmoidoscopies after the patient with the blood borne virus.


- Ten patients with blood borne viruses had had sigmoidoscopies and 20 patients had had sigmoidoscopies after the patient with the blood borne virus. These patients were contacted and offered blood borne virus testing at a special clinic and then via their GP. 18 were successfully contacted and tested and all tested negative


- The process was complicated as some of the patients were identifiable only by sexual health numbers and dates of birth. The look back extended over 8 years and the hospital information systems had changed during this time period. The presentation will outline the detailed process involved in identified exposed patients along with the internal and external communications used. Funding Not applicable
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