Description of Event or Problem · 1
(B)(6) YEAR OLD FEMALE REFERRED TO CLINIC FOR DYSPHAGIA FOLLOWING MOTOR VEHICLE ACCIDENT WITH BLUNT THORACIC AORTIC INJURY. EGD PERFORMED IN (B)(6) 2019 SHOWED CHRONIC GASTRITIS. WHEN USING BIOPSY FORCEPS DURING EGD PROCEDURE, IT APPEARED THAT THE FORCEPS PUSHED OUT A 1 MM PIECE OF DRIED TISSUE OR SOLID MATERIAL FROM THE INTERIOR CHANNEL. IT WAS PRESUMED THAT THE MATERIAL WAS PICKED UP AS THE FORCEPS PASSED THROUGH THE CHANNEL OF THE EGD SCOPE. THE PHYSICIAN ATTEMPTED TO OBTAIN THE MATERIAL WITH THE FORCEPS AND IMMEDIATELY REMOVED AND SEQUESTERED THE SCOPE. WHEN SCOPE WAS REMOVED, NO MATERIAL WAS FOUND TO BE IN FORCEPS. THE FORCEPS DID CONTAIN A SMALL AMOUNT OF BLOOD MIXED WITH MUCUS. FORCEPS WERE WIPED WITH GAUZE TO OBTAIN ANY REMAINDER OF THE MATERIAL. SCOPE WAS FLUSHED WITH STERILE WATER. NO GROSS DEBRIS FOUND. FLUSH AND BRUSH TIPS THAT WERE USED TO CLEAN THE CHANNEL AS WELL AS THE GAUZE USED TO WIPE THE FORCEPS WERE SENT TO OFF-SITE LAB FOR DNA TESTING. THE DNA TESTING IS CURRENTLY PENDING. THE SCOPE WAS PROCESSED PER MANUFACTURER¿S INSTRUCTIONS AND NO PROCESSING ISSUES WERE IDENTIFIED. A MICRO-CAMERA WAS USED TO VISUALIZE THE INSIDE OF CHANNEL FOR ANY DEFECTS OR BIOBURDEN. INSIDE THE CONTROL BODY, APPROXIMATELY WHERE THE INSERTION TUBE BOOT ATTACHES TO THE GRIP, SEVERE BUCKLING IS NOTED THAT COULD CONCEIVABLY TRAP BIOBURDEN. THE MANUFACTURER WAS NOTIFIED AND THE SCOPE WAS SENT TO MANUFACTURER FOR REPAIR. PATIENT (B)(6) WAS NOTIFIED OF THE MATERIAL SEEN ON THE ENDOSCOPE DURING THE PROCEDURE AND THAT A FULL INVESTIGATION WAS BEING CONDUCTED ON (B)(6) 2019. THE PATIENT WAS NOTIFIED ABOUT THE DAMAGE TO THE SCOPE DURING A FOLLOW-UP CLINIC APPOINTMENT ON (B)(6) 2019. BASELINE SEROLOGIES TO INCLUDE (B)(6) WERE DRAWN ON (B)(6) 2019. BASELINE RESULTS SHOW NO ACTIVE INFECTION AND PATIENT WITH (B)(6) INDICATING SHE SUCCESSFULLY RESPONDED TO VACCINE. UPON INVESTIGATION, IT WAS DETERMINED THAT SCOPE HAD BEEN PREVIOUSLY USED ON A PATIENT ON (B)(6) 2019. THIS PATIENT IS ALSO TO BE BROUGHT IN FOR BASELINE SEROLOGIES TO INCLUDE (B)(6). DNA TESTING ON THE STERILE WATER FLUSH, THE BRUSH TIPS AND THE GAUZE IS STILL PENDING WITH EXPECTED RESULTS IN 4 WEEKS. THIS SCOPE WAS PURCHASED IN AUGUST OF 2018. IT WAS SENT FOR REPAIR ON 11/16/2018. REPAIR WORK INCLUDED BENDING THE SECT. DISTAL TIP FILE, REGLUE AND AIR/ WATER CYLINDER REPLACEMENT. WORK WAS COMPLETED BY THE MANUFACTURER ON 11/20/2018 AND THE SCOPE WAS RETURNED TO THE ORGANIZATION.