Endoscope decontamination incidents in England 2003-2004.

An Endoscope Task Force was established following the report of an endoscope decontamination failure in May 2004. The Task Force reviewed endoscope decontamination incidents in England from 2003 to 2004 and made recommendations to prevent further recurrences. Twenty-one incidents were reported from 19 National Health Service (NHS) Trusts, 18 of which matched the Task Force definition of an incident. Eight incidents involved failures to decontaminate auxiliary endoscope channels, seven incidents highlighted problems with automated endoscope reprocessors, and the remaining three involved disinfection practices not recommended by the British Society of Gastroenterology Guidelines. Following an assessment of the risk of transmission from blood-borne viruses, the Task Force recommended that look-back exercises were not indicated. The nature of the incidents suggested that there were problems associated with defining roles and responsibilities for endoscope decontamination, staff training and incompatibility between endoscopes and reprocessors. The Medicines and Healthcare Products Regulatory Agency subsequently issued recommendations to all NHS Trusts carrying out endoscopies.