Contaminated surgical tools found in Grande Prairie operating room in April, AHS records show

Contaminated medical instruments found their way into an operating room at the Grande Prairie Regional Hospital (GPRH) on at least two occasions this year, according to Alberta Health Services’ meeting notes that were acquired by CBC News via an Access to Information and Privacy request.

Their discovery postponed some surgeries at the hospital, while using steam to sterilize surgical equipment was outsourced to Edmonton during the spring.

The documents, which include meeting notes, memos and surgery cancellation data, said a similar incident happened about two years earlier.

The incidents show gaps throughout the sterilization process and across multiple teams, the documents state, “including surgeons, operating room staff and Medical Device Reprocessing (MDR).”

Elective surgeries postponed at Grande Prairie hospital due to surgical tool sterilization issues

Meeting notes identified instances on March 10 and April 15 where dirty medical instruments were found following the sterilization process.

During the March 10 incident an orthopedic instrument “contained a retained guidewire and visible tissue from a previous case” after the cleaning process.

Another orthopedic instrument with retained tissues was discovered during a surgery on April 15. The instrument had not been used during the procedure, but the meeting notes said “another instrument from the same contaminated set was used to complete the surgery.”

Although the documents did not state what kind of "retained tissue" was found on the instruments, Ontario-based retired infectious disease specialist Dick Zoutman told CBC News that finding dried blood, bone fragments, tissue, dried cement or water spots on instruments can occur when the MDR process fails.

“That's not supposed to be there and shouldn't ever happen. It's indicative of a serious problem in the quality of the reprocessing,” said Zoutman, who previously worked as chief of staff in two different Ontario hospitals.

Zoutman said orthopedic instruments can be complex pieces of machinery that involve gears, ratchets and other moving parts that require intricate cleaning. He also said there is no excuse for them not being properly reprocessed.

“They were very careful and did the right thing,” Zoutman said of the scrub nurse who found the contaminated tool during the April 15 procedure.

“That's a very good thing to keep the patient safe. However, it shouldn't have happened in the first place. There should have never been debris on these instruments.”

An AHS spokesperson told CBC in a Aug. 7 email that mandatory cleaning, disinfection, sterilization and documentation take place during that reprocessing process.