Cleaning and Disinfection Failure in an Endoscopy Suite

Ranking by potential harm:

1. Unverified disinfectant concentration is the highest risk. High-level disinfection depends on the solution being at or above its minimum effective concentration. A log that records only 'checked' without a value means no one can demonstrate the solution was effective. Four days without a documented result is a serious gap; the solution may have been reused beyond its capacity.
2. Manual reprocessing during an AEP outage is a recognized high-risk period. Manual reprocessing is more error-prone, and duodenoscopes in particular have been linked to outbreaks because of their complex elevator mechanism. The IP should verify that the manual protocol includes brushing the elevator and that staff are competent.
3. Damp scope in an unventilated cabinet is a storage breach. Residual moisture promotes biofilm and microbial growth; scopes should be stored hanging, dry, and in a well-ventilated cabinet. A visibly damp channel indicates inadequate drying (for example, no alcohol flush and forced-air dry).
4. Throughput pressure - 12 procedures a day with a backlog and a broken AEP creates pressure to cut corners on dry time and contact time.
5. The brush-and-rinse step appears present, which is a positive, but the IP should confirm channel brushing of all lumens and that the brush is the correct size.

Patient safety outranks throughput:

• Quarantine the scopes in the cabinet, including the damp one, and do not use them until they are reprocessed and dried per protocol. The damp scope should be fully reprocessed, not just wiped.
• Assess whether patients were exposed. Determine which scopes were processed during the period when concentration was unverified and which patients underwent procedures with them. This is a look-back; the IP should work with the medical director and risk management to decide on notification and, where indicated, screening for the organisms of concern (for example, carbapenem-resistant Enterobacterales).
• Do not simply resume the backlog. The suite should suspend or sharply limit procedures until the AEP is restored or the manual process is validated - including documented concentration testing before each session, full contact time, and drying. If capacity must continue, the IP should require a second-person verification of each manual cycle.
• Escalate the AEP outage to facilities and leadership as an urgent equipment issue, with a documented interim plan and a target restoration date.
• Communicate with the endoscopy team about why the pause is necessary, so the pressure to catch up does not silently reopen the breach.

Corrective actions should target the system, not just the individuals:

• Disinfectant management: require recording of the actual test-strip result and the date/time for every session, with a defined minimum effective concentration and a rule that the solution is discarded when it fails. Consider moving to a system that documents automatically.
• Competency and observation: retrain and directly observe all reprocessing staff on the manual protocol, including elevator brushing, all-lumen flushing, contact time, alcohol flush, and forced-air drying. Build in periodic observed audits rather than relying on self-report.
• Storage: repair or replace the cabinet so it is ventilated, and require that scopes be confirmed dry before hanging. Add a visual check to the daily routine.
• Equipment redundancy: establish a maintenance and backup plan so that an AEP outage triggers a defined protocol rather than an ad hoc workaround, and so leadership knows the risk.
• Monitoring and reporting: track reprocessing audits, disinfectant test compliance, and any positive cultures or cluster signals; report to the infection control committee. Re-audit after 30 and 90 days to confirm the fixes held.