After deliberating for less than an hour, a jury in Allegheny County Common Pleas Court has decided that Forbes Regional Hospital in Monroeville was negligent in failing to properly clean and sterilize colonoscopes used on more than 225 patients in 2004 and 2005.
The decision in the class-action lawsuit, which also names Forbes' parent corporation, West Penn Allegheny Health System, as a defendant was reached on Thursday before Senior Judge R. Stanton Wettick Jr. It sets the stage for individual jury trials to decide what, if any, damages should be awarded to those patients for their pain and suffering, inconvenience and "loss of life's pleasures," said David Paul, one of the attorneys who tried the case.
Most of his clients will never again be able to enter a hospital or a doctor's office and feel completely comfortable, he said.
"It's the mental anguish of realizing over and over again that you were subjected to a colonoscopy with a dirty scope," Mr. Paul said. "There's a psychic harm to realizing you will never again trust another hospital."
Dan Laurent, spokesman for the West Penn system, declined to comment on the decision.
After discovering the errors, Forbes Regional's CEO urged affected patients to be tested for bloodborne communicable diseases despite the low risk of contracting them, then undergo a second round of testing six months later. The hospital paid for the tests.
None of the patients contracted a disease as a result of their exposure.
In February 2003, the manufacturer of Forbes Regional's colonoscopes, Olympus America, sent the hospital's recall officer a warning that some models contained an auxiliary water channel that needed to be cleaned and sterilized with special equipment from the manufacturer to protect patient safety. The recall officer sent the warning to the head nurse in charge of the hospital's gastrointestinal lab, asking if the hospital was using those scopes, but it was not.
The warning was filed with the recall officer, but the head nurse -- who, contrary to testimony from the recall officer and hospital executives, testified she never saw the warnings -- did not keep a copy.
When hospital executives purchased two new Olympus colonoscopes the following year, they did not include the recall officer in the requisition process, and testified they were not aware of the need for special cleaning procedures, Mr. Paul said.
On Oct. 27, 2004, Forbes Regional Hospital received the new colonoscopes, which included the new auxiliary channels. The scopes' model numbers differed from those on the scopes already in use at the hospital, and the boxes included special equipment needed to clean and sterilize the new auxiliary channels, according to Mr. Paul.
The head nurse in charge of the gastrointestinal clinic where the scopes were to be used, however, did not unpack that cleaning equipment or read any of the enclosed instruction manuals, which contained multiple warnings that the colonoscopes required special cleaning to ensure proper sterilization, he said.
"They took that special equipment and the instruction manuals that came with the new colonoscopes, stuck them back in the box and stuck the box in a storage closet," Mr. Paul said.
The hospital began using the scopes Oct. 29. At one point after the scopes arrived, Mr. Paul said, a gastrointestinal lab technician noticed they had an extra channel but that the cleaning equipment they were using on it did not have a corresponding tube for cleaning fluid, and brought it to the attention of the head nurse. The technician testified the head nurse told her she didn't need to do anything differently to clean the new scopes, he said.
The first sign of a problem was discovered Feb. 2, 2005.
"One of the scopes was hanging up after supposedly being cleaned and sterilized and it was dripping fecal matter," Mr. Paul said.
The scope was taken out of use and examined by an independent equipment trouble-shooting company, which found no problems. The scope -- which was functioning as designed but hadn't been cleaned according to the new procedures -- was put back into use, Mr. Paul said.
A few weeks later, the second scope also was found to be dripping fecal matter after supposedly having been cleaned and sterilized. It, too, was examined and found to be working properly, Mr. Paul said.
Both scopes then were taken out of use and the head nurse contacted the manufacturer. The company's representative asked the nurse if Forbes Regional's technicians were cleaning the auxiliary water channel, Mr. Paul said.
"She asked, 'What's the auxiliary water channel?' " he said.
After the mistake became clear, hospital officials contacted the more than 225 patients who were determined to have been examined with the new scopes to inform them of possible exposure to bloodborne pathogens and to advise them to seek testing.
At trial, the hospital's defense was that the manufacturer's representative had not specifically, verbally informed the head nurse that the new scopes had a special feature, Mr. Paul said. The head nurse testified that it wasn't her job to know the difference between these new scopes and the old scopes, but rather the Olympus representative's job to tell her, he said.
In 2002, a patient at Allegheny General Hospital -- also in the West Penn Allegheny Health System -- died from a bacterial infection that was linked to contaminated bronchoscopes, which are used to examine the lungs.
"People get stale and when people get stale in a hospital setting, and fail to dot all their i's and cross all their t's, bad, bad things can happen," he said.
First Published: July 22, 2012, 4:00 a.m.
