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Sherlock Holmes: Whose Tissue Is It Anyway?

Published online by Cambridge University Press:  02 November 2020

Bonita Lee
Affiliation:
University of Alberta
Jason Silverman
Affiliation:
University of Alberta
Atilano Lacson
Affiliation:
Alberta Health Services
Iyare Izevbaye
Affiliation:
University of Alberta Hospital
Hien Huynh
Affiliation:
Department of pediatrics, University of Alberta
Consolato Sergi
Affiliation:
University of Alberta
Remegio Maglantay
Affiliation:
University of Alberta Hospital
Cheryl Mather
Affiliation:
Alberta Precision Laboratories Ltd.
Adrian Box
Affiliation:
Alberta Health Services
Teresa Paonessa
Affiliation:
Alberta Health Services
Rebecca Nawaz
Affiliation:
Alberta Health Services
Jesusa Pulongbarit
Affiliation:
Alberta Health Services
Mario Tremblay
Affiliation:
Alberta Health Services
Kathy VanVeen
Affiliation:
Alberta Health Services
Joan Durand
Affiliation:
Alberta Health Services
Melody Cordoviz
Affiliation:
Alberta Health Services
Nancy Aelick
Affiliation:
Alberta Health Services
Catherine Williamson
Affiliation:
Alberta Health Services
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Abstract

Background: The medical device reprocessing department (MDRD) is a crucial patient safety area with checkpoints to ensure appropriate reprocessing. Objective: We report the application of molecular pathology in the investigation of potential blood and body fluid exposure (BBFE) during endoscopy. Methods: When there is a potential BBFE from a medical device, our hospital has a systematic process whereby the clinical area involves the MDRD and the infection prevention control (IPC) team. The MDRD provides reprocessing documentation, including detailed information regarding the prior use of the devices. The clinician and the IPC physician discuss the risk of BBFE. If patient disclosure occurs, the IPC physician provides follow-up as appropriate. This report illustrates the collaboration of clinicians, the IPC team, the MDRD, pathologists, and molecular pathologists in investigating the possibility of residual human tissue and BBFE during endoscopy. Case reports: Two independent but similar events occurred in September 2016 and September 2019 in the pediatric endoscopy suite at our site, a tertiary-care pediatric hospital with 163 beds in Edmonton, Canada. During both endoscopies, the pediatric gastroenterologists observed a piece of tissue ejected from the gastroscope into the intestinal lumen when the biopsy forceps were pushed out of the channel for the first time. This observation raised concerns of possible gaps in the reprocessing of the endoscope and residual tissue remaining in the working channel after its last use. Both gastroenterologists were able to retrieve the presumed foreign tissue; however, both patients had possible BBFE because the mucosal surface was breached by the biopsy forceps. The MDRD reprocessing of both endoscopes was reviewed, and no gap was identified. In discussion with the pathologists and molecular pathologists, human identity testing using genetic markers was performed on the biopsy blocks of the previous patient on whom the endoscope was used, the potentially exposed patient, and the presumed foreign tissue for each event. The test results indicated that the presumed foreign tissue was in fact from the potentially exposed patient and therefore there was no BBFE. It is presumed that the working channel itself captured a small amount of the patient’s tissue during scope insertion. The results were a relief to the patients and families. Conclusions: It is prudent to investigate residual foreign tissue in a medical device that is being used on patients with mucosal breaches. Molecular pathology involving human identity testing is a very useful tool in the investigation of these types of events.

Funding: None

Disclosures: None

Type
Poster Presentations
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.
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