Abstract：
BACKGROUND:Most cases of microbial transmission to patients via contaminated endoscopes have resulted from nonadherence to reprocessing guidelines. We evaluated the occurrence, features, and implications of reprocessing lapses to gauge the nature and breadth of the problem in the context of widely available and accepted practice guidelines. METHODS:We examined peer-reviewed and non-peer-reviewed literature to identify lapses reported in North America during 2005 to 2012 resulting in patient exposure to potentially contaminated gastrointestinal endoscopes. RESULTS:Lapses occurred in various types of facilities and involved errors in all major steps of reprocessing. Each lapse continued for several months or years until the problem was discovered except for one that was described as a single incident. There were significant implications for patients, including notification and testing, microbial transmission, and increased morbidity and mortality. Only 1 reprocessing lapse was found in a peer-reviewed journal article, and other incidents were reported in governmental reports, legal documents, conference abstracts, and media reports. CONCLUSION:Reprocessing lapses are an ongoing and widespread problem despite the existence of guidelines. Lack of publication in peer-reviewed literature contributes to the perception that lapses are rare and inconsequential. Reporting requirements and epidemiologic investigations are needed to develop better evidence-based policies and practices.
journal_name
Am J Infect Controljournal_title
American journal of infection controlauthors
Dirlam Langlay AM,Ofstead CL,Mueller NJ,Tosh PK,Baron TH,Wetzler HPdoi
10.1016/j.ajic.2013.04.022subject
Has Abstractpub_date
2013-12-01 00:00:00pages
1188-94issue
12eissn
0196-6553issn
1527-3296pii
S0196-6553(13)00974-7journal_volume
41pub_type
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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doi：10.1016/j.ajic.2005.05.012
更新日期：2006-02-01 00:00:00
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journal_title：American journal of infection control
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更新日期：1999-02-01 00:00:00
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journal_title：American journal of infection control
pub_type： 杂志文章,评审
doi：10.1016/j.ajic.2006.09.005
更新日期：2007-03-01 00:00:00
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pub_type： 杂志文章
doi：10.1016/s0196-6553(96)90047-4
更新日期：1996-02-01 00:00:00
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journal_title：American journal of infection control
pub_type： 杂志文章
doi：10.1016/j.ajic.2018.04.205
更新日期：2018-10-01 00:00:00
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journal_title：American journal of infection control
pub_type： 临床试验,杂志文章
doi：10.1016/s0196-6553(97)90082-1
更新日期：1997-10-01 00:00:00
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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更新日期：2000-08-01 00:00:00
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journal_title：American journal of infection control
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更新日期：1990-06-01 00:00:00
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journal_title：American journal of infection control
pub_type： 杂志文章
doi：10.1016/j.ajic.2010.06.022
更新日期：2010-12-01 00:00:00
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journal_title：American journal of infection control
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更新日期：2012-08-01 00:00:00
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journal_title：American journal of infection control
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更新日期：2005-10-01 00:00:00
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journal_title：American journal of infection control
pub_type： 杂志文章
doi：10.1016/j.ajic.2013.06.004
更新日期：2014-01-01 00:00:00
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journal_title：American journal of infection control
pub_type： 杂志文章
doi：10.1016/j.ajic.2013.10.006
更新日期：2014-03-01 00:00:00
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journal_title：American journal of infection control
pub_type： 杂志文章
doi：10.1016/j.ajic.2015.05.012
更新日期：2015-10-01 00:00:00
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journal_title：American journal of infection control
pub_type： 杂志文章
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更新日期：2010-03-01 00:00:00
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journal_title：American journal of infection control
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更新日期：2017-04-01 00:00:00
