Officials at General Wood Army Community Hospital, located in Missouri, are reaching out to approximately 135 former surgical patients with bad news about potential exposure to infections during their procedures. The hospital at Fort Leonard Wood determined they were inadequately sterilizing a piece of laparoscopy equipment that was new to the facility.

“During the course of the routine sterilization, a piece came apart, at which point we did some digging and determined that that piece was supposed to be taken apart each and every time that we sterilized it,” Christian Meko, the commander of the hospital, told KSPR-TV.

Sterilization personnel in the hospital weren’t following those instructions for use when the equipment was actively employed from August 1 of last year to January 26 this year. Hospital officials note the equipment was removed from use as soon as the discrepancy was discovered, and relevant staff was quickly given new training to bring their practices in line with manufacturer recommendations.

Concerned about the potential repercussion on patients who underwent procedures utilizing the device, the hospital reached out for help.

“We contacted a number of infectious disease experts across the country with similar experiences, and just ran them through exactly what our process is for general sterilization and what we found,” Meko told KSPR. “They all concluded that it was extremely low risk the chance that any infection would have occurred.”    

Letters have been sent to patients who may have been impacted by the improperly sterilized device, and the hospital plans to hold town hall meetings to answer any concerns.

“As a high reliability organization, we seek to continuously improve the safety and quality of care at GLWACH,” Meko said in a statement. “We take any potential risk to patient safety very seriously and are committed to doing all we can to mitigate any risks. We have reported the event to The Joint Commission.”