Incomplete sterilisation of equipment

On Monday (11 February) Hawke’s Bay District Health Board became aware of an issue with a batch of sterilising equipment that was used in Hawke’s Bay Hospital operating theatres, sent to outpatient clinics and used by district nurses between 2 February and 11 February.

While this batch of equipment was properly cleaned, heated to a very high temperature and dried, the final sterilisation process was not completed as it should have been.

Hawke’s Bay DHB chief executive Dr Kevin Snee said the DHB immediately consulted with local and national experts from ESR (the institute of Environmental Science and Research) as well as Hawke’s Bay Hospital’s infectious disease specialist Dr Andrew Burns who determined the risk to patients being exposed to infection was very remote. However, the DHB has put the following steps in place:

  • Upon discovery, the DHB activated its Incident Management System with identification of patients who may have come into contact with the equipment, including analysis of risks to those patients.  
  • The DHB is confident this was a one-off event with a thorough review or all equipment and process immediately undertaken.  
  • The DHB has identified everyone who may have come into contact with the equipment that was used. 
  • The DHB has now spoken directly with the majority of patients who have been identified at higher risk due to having invasive surgery. (Note: We say the majority as some patients we have not been able to get hold of and are still trying). These patients are being asked to come back to hospital where they can be assessed in clinic, and advised of the steps we are taking to manage their health as a result of this. 

“Understandably the DHB is seeking answers as to how this failure occurred and we have launched an investigation to understand how this happened.  This investigation will also be externally reviewed,” said Dr Snee. 

“The DHB unreservedly apologises for any distress this has caused and we will be working closely with those affected. However, we would like to reassure the public of the expert scientific advice we have received to emphasise how small the risk of infection is.

“We encourage anyone concerned to contact us via the call centre if they believe they are affected.  Call 878-8109 and ask to be put through to the person managing the incomplete sterilisation.

“The DHB will continue to be open and transparent as we work through this process.”

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