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Newly uncovered report suggests Huntington Memorial patient deaths linked to superbug outbreak

par Thomas Dworetzky, Contributing Reporter | May 06, 2016
Infection Control Medical Devices Risk Management
Early this year, Olympus recalled one of its duodenoscopes, Model TJF-Q180V, which had been linked to a superbug outbreak at UCLA Ronald Reagan Medical Center. Now a second model of its duodenoscope has been implicated in the deaths last year of three Huntington Memorial Hospital hospital patients.

A newly surfaced FDA report has suggested that an older Olympus scope used since 2002 at Huntington, Model TJF-160F, may have also caused fatalities last year, according to the Los Angeles Times.

An investigation was launched last August by The Pasadena Public Health Department.
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In a statement at the time, Steve Ralph, President and CEO of Huntington Memorial, announced that the devices had been quarantined, that federal investigators were looking into the situation and that “elective surgeries were temporarily halted Monday evening and resumed Tuesday," according to Pasadena Now.

The hospital on Thursday would not confirm the deaths or disclose how many patients may have been infected. But Olympus said the hospital reported three patients died in connection to the outbreak, according to a filing with the FDA.

This week the hospitals chief medical officer Paula Verette said that an outreach was started to patients to contact everyone "who underwent a procedure using an Olympus scope in the preceding months,” and that the effort continues to monitor their health status, according to the online news service.

While investigators would not discuss the situation at Huntington, several nurses told Pasadena Now that they had found errors with surgical trays that made them "not sterile."

“When they encountered the same situation in three trays, the auditors ordered that the entire inventory of trays had to be taken down and reprocessed,” Tina Gold, a former Huntington Hospital OR nurse alleged to PN. She also claimed to be in regular contact with former colleagues. “This massive undertaking led to the cancellation of 38 elective [surgery] cases.”

Medical Safety Expert Lawrence Muscarella told the Pasadena Star News he uncovered the deaths by tracking FDA “adverse event” reports, of which there have been almost 30 involving scopes, reported by Olympus since 2014. Why the Huntington hospital did not publicly share test results for the devices, nor state the number of patients exposed, mystifies him.

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