UPMC Failed to Ensure Sterility of Surgical Instrument

By Walter F. Roche Jr.

A worker at a Williamsport hospital failed to adequately cleanse a surgical insrument and bacterial matter fell into a patient's surgical field while undergoing laparoscopic surgery, according to a report from the state Health Department.
The report, which was just made public, concludes that UPMC Williamsport, a 224 bed hospital, failed to ensure staff followed approved procedures for the cleansing and disinfection of surgical equipment.
According to the report a trocar which was being used in a Sept.9 laparoscopic procedure had not been properly cleaned and "bioburden fell from the distal end of the trocar into the patient's surgical field."
"The bioburden was retrieved and the surgical field was flushed," the report continues, adding that additional antibiotics were added to the patient's post operative orders.
The facility was also cited for failing to properly report the incident.
"The facility failed to document a surgical complication in the medical record," the report states, adding that the incident was not noted in the surgeon's operative or progress notes. The report states that a review of records showed there was no documentation of the disclosure of the incident to the patient on the day after the surgery.
Tyler Wagner, a hospital spokesman wrote in an email response to questions, that the hospital was cooperating with state health officials and has adopted a corrective action plan to address the issues in the complaint.
"The plan has been reviewed and accepted by the Pennsylvania Department of Health," Wagner wrote.
In the same report, state health surveyors failed to properly respond to patient grievances. in some cases the patients were not provided either an interim or final report on the findings on the complaints.
In another finding the state said records showed patients were discharged from a recovery room without written orders from a physician. Some patient records lacked required signed informed consent forms, the surveyors reported.
The hospital filed plan of correction in which it detailed steps taken to correct the errors and prevent any recurrence. Staff, according to the plan, were re-educated on the proper way to clean and sterilize surgical equipment.
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