RE Official Information Act request WCDHB 9298
I refer to your email dated 6 March 2019 to the Ministry of Health which was subsequently transferred to our office on 22 March 2019 requesting the following information under the Official Information Act from West Coast DHB.
I would like a detailed breakdown of any and all incidents relating to equipment not being properly sterilised by District Health Boards in 2018 and 2019
There have been no incidences of equipment not being properly sterilised by the West Coast Health Board during the period 1 January 2018 to 22 March 2019.
Three cases were identified as being potentially improperly sterilised during this time period; but in all three cases, this was a precautionary risk mitigation in response to sterility indicators, rather than anything at all to do with actual equipment sterilisation, or of the sterilisation safety processes. Two cases that were identified as a potential risk related to theatre instruments which showed incorrect colour on the highly chemically-sensitive sterilisation indicator tape, signalling the items as being potentially unsterile. In this event, the steriliser units were thoroughly tested and validated for sterility. The third case involved the discovery of a wet patch on the inside a wrapped instrument tray during surgical set-up. While not necessarily depicting an unsterile load in itself, the presence of a wet patch from internal accumulated condensation from the drying of the wrapped equipment in this case was treated as if it was potentially at risk for sterility, and the equipment was exchanged.
All three potential issues were detected via the sterilisation warning indicator strips and clinical safety systems checks before use, and the items were replaced by equipment showing definitive positive markers for sterility in accordance with established protocols. Indicators and parameters for sterility for all other items sterilised by West Coast DHB have been met for all other areas and services.
Additionally, West Coast DHB maintains a tracking system for all equipment and instruments used for each patient going through our operating theatres to counter-check for sterility for any prostheses and other items used in operating room procedures that may be supplied by agencies external to our own. All indicators and parameters for sterility for such items used by West Coast DHB during this time have been met.