Operating tools improperly sterilized is a process flaw, HQC says

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An organization that aims to improve the quality of health care in Saskatchewan said it’s disappointed by a recent mistake made at Saskatoon City Hospital.

Earlier this month, staff didn’t complete a final step in sterilizing tools for 13 surgeries.

“I was disappointed to hear that,” said Dr. Dennis Kendel, the interim CEO for the Sask. Health Quality Council (HQC).

“But it’s understandable that these things happen.”

Kendel said human error is bound to happen in complex industries such as health care. However it’s important not to blame one person – but instead, look at the issue from a process perspective.

“It wouldn’t be helpful to say a particular person was responsible, because that just blames a person and doesn’t remedy the process,” said Kendel.

The operating instruments missed the final sterilization step, meaning some patients could be exposed to fungi and bacteria. A nurse flagged the issue after noticing an indicator didn’t change colour to show the equipment was fully sterile.

The Saskatchewan Health Authority is investigating the issue.

The HQC said it hopes the findings will be shared not with just Saskatoon City Hospital, but all Saskatoon hospitals to avoid repeating the issue.





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