Dozens of patients may have been exposed to infection due to a possible lapse in cleaning and disinfecting procedures at the Regional Fertility and Women’s Endocrine Clinic in Edmonton last month.
Alberta Health Services (AHS) is in the process of notifying 141 patients of the fertility clinic at the Royal Alexandra Hospital, that patients who underwent an endovaginal ultrasound at the clinic between Nov. 14 and Nov. 20 may be at “exceedingly low risk” of exposure to blood-borne and sexually transmitted infections.
An endovaginal ultrasound involves inserting a thin wand or probe into a woman’s vagina in order to examine the female reproductive organs.
AHS first became aware of this issue on Nov. 20. A review found human error in following AHS’ “standards of excellence in Medical Device Reprocessing” (MDR) was to blame.
AHS said that included inconsistent tracking and documentation of the number of reprocessed probes available for endovaginal ultrasounds, and overscheduling of procedures.
The health agency said MDR is an essential service within a health care setting that includes the provision of safe surgical and diagnostic equipment. This includes procedures for consistent tracking and documentation, and scheduling of procedures – which AHS said in this case were not followed properly.
AHS said it is notifying patients because it can’t be certain all MDR practices within the clinic were conducted according to its usual high standards, including the way staff tracked and recorded the number of reprocessed probes available for endovaginal ultrasounds, and the proper cleaning and disinfection of the ultrasound probes used during this timeframe.
AHS stressed the risk of an actual infection is near zero.
“While it is likely that most patients involved would have had procedures with cleaned and disinfected ultrasound probes, we cannot be absolutely confident about this. As such, and in keeping with AHS values, disclosure of this MDR issue was provided to all impacted patients,” an AHS statement said.
The news came a few weeks after AHS announced the clinic was cancelling non-insured services, including in-vitro fertilization and intrauterine insemination.
“It’s very disheartening,” said Alberta Party MLA Karen McPherson, who is also an advocate of keeping infertility treatment services intact and accessible.
“Fertility clinic patients have already been through so much, and now they learn they may have been exposed to harmful diseases. I do not feel as though these women are getting the health care they need and deserve as Albertans.”
While risk of infection is considered exceedingly low, those who do wish to be tested will be provided with instructions for simple blood and/or urine testing that can rule out infection.
AHS said it has now put in place stronger logging and monitoring processes at the clinic.
In order to prevent this type of error from happening in the future, AHS said it has:
- Ensured that the maximum capacity for ultrasounds is not exceeded by having ultrasound bookings monitored daily by the unit manager
- Placed qualified and certified MDR technicians in the clinic to perform all reprocessing
- Increased staff education on medical device reprocessing
- Implemented a new practice that an educator from RAH’s Medical Device Reprocessing Department (MDRD) review the clinic’s reprocessing standards, confirming staff competency and daily monitoring