Within a one-month period in 2007, seven patients in a Vegreville, Alberta hospital were ill with an antibiotic-resistant bacterial infection. Health officials closed the 25-bed hospital, and patients who had visited the hospital over the previous four years were contacted to undergo testing for blood-borne infections such as hepatitis B and C, as well as Human Immunodeficiency Virus (HIV). Equipment was not being properly sterilized, leading to the possible spread of infection. A subsequent report by the Health Quality Council of Alberta found management deficiencies not only at the sterilization unit, but also at the hospital and the regional health authority. A highlight of the root cause analysis was on the knowledge and clarity of roles for organizations and the sense that lines of accountability were not clear for board members around quality and patient safety between organizations and in the region. Boards must understand their accountabilities for quality and patient safety.
Review of the Infection Prevention and Control and CSR Sterilization Issues in East Central Health Region, Health Quality Council of Alberta, June 2007.