There are few more frightening phone calls that a surgical patient could receive than one notifying them that "Our sterilization processes failed. You may be infected with HIV, hepatitis B, or hepatitis C."
A million thoughts go racing through the mind - "I had a knee replacement. What does that have to do with HIV?" -- "What's the life expectancy of someone with hepatitis C?" -- "What about my friend who had surgery a month after I did? Are they at risk for hepatitis B as well?" -- "How could this happen?"
This was the experience of 18 months worth of surgical patients from Porter Adventist Hospital in Denver, Colorado this month, as they were notified of "an infection-control breach involving surgical instruments." Specifics to this story are still sparse, but particular attention has been given to the potential issues related to "pre-cleaning" and "water quality" as referenced in various news reports. Knowing what we do know about this quality breakdown, and related issues such as at Detroit Medical Center, there are at least 5 critical lessons we need to take away from this event: