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2,500 Women Potentially Exposed to HIV

2,500 Women Potentially Exposed to HIV

ER-SPEC Vaginal Speculum

What happens when one clinic fails to follow sterilization rules? Almost 2,500 women were potentially exposed to HIV and other infectious diseases when a hospital colposcopy clinic in Canada failed to use standard sterilization procedures on their equipment.

In 2013, Horizon Health Network sent registered letters to their patients explaining that they needed to be tested for HIV, hepatitis C and hepatitis B. The medical service discovered the colposcopy clinic located at Miramichi Regional Hospital was not following infection control guidelines. For 14 years, they had failed to properly sterilize the medical tools used for examinations and procedures.

The malpractice was reported to Horizon by an employee of the clinic. The staff member stated that forceps used in the examinations of their patients were not always sterilized using the North American standard as required. The clinic often used a high-level disinfection procedure able to kill most pathogens instead of full sterilization that would eliminate all the risk of cross-contamination.

The reason for the variation was a supply shortage, according to Horizon. The volume of patients exceeded the number of available, sterilized forceps. Full sterilization was an overnight process, so the staff had to come up with a solution during their operating hours to give them an adequate supply of this critical tool.

The decision was made 14 years ago to disinfect in order to deal with their current shortage and they failed to revert back to the proper system or to increase their supply to cover the patient load. It was an oversight on the part of the clinic.

The employees at the colposcopy clinics performed the disinfection procedure perfectly, so there is little risk of cross-contamination. The hospital network decided to disclose the infraction just to reassure their patients and offer screening. Only women who had biopsies before May 24, 2013 are at risk. After that time, the clinic adjusted their guidelines and sterilization practices.

After the discovery at their New Brunswick hospital, Horizon Health Network investigated all of their sites to confirm they use proper sterilization on their tools and equipment.

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