Colorado investigation into Porter Adventist sterilization breach found bone, blood, bugs on tools

DENVER – The state’s completed investigation into a sterilization breach at Denver’s Porter Adventist Hospital found some surgical instruments were left with chunks of bone, blood, a dead bug and cement, among other things.

The Colorado Department of Public Health and Environment’s investigation was completed April 17 after it was initiated Feb. 22 when the breach was first discovered.

The investigation found 76 instances of contaminated surgical instruments and trays being used at the hospital between Jan. 1, 2017 and April 2 of this year. Along with the aforementioned items found on the instruments and trays, investigators also found hair and black residues.

The probe found that because the instruments weren’t sterilized in a timely or proper manner, surgeries were delayed and, in some cases, were interrupted.

It also found that during the “system failures,” the hospital failed to report some infections that stemmed from the sterilization breach to the Centers for Disease Control’s National Healthcare Safety Network because it couldn’t adequately track the infections.

The CDPHE has approved the hospital system’s plan of correction with new oversight and tracking steps and will be conducting an unannounced visit to be sure the issues have been fixed.

The CDPHE says it is also in the process of figuring out whether or not it will sanction any of the hospital’s licenses. The Centers for Medicare and Medicaid Services, which has certified the hospital, can also sanction Porter Adventist if it chooses.

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