Is a lumen really cleaned if you can’t see down it?

Mrs Marija Juraja1,2

1Andrew Ellis, Adelaide , Australia, 2Diana Lagana, Adelaide, Australia


In hospitals every day we use equipment that is cleaned and sterilized, but is it? In late 2016 we found a device that has been used for years and subsequently found that it wasn’t as clean as we thought!


In 2017 whilst our CSSD staff were cleaning and reprocessing a rigid lumen scope, they found unusual debris moving out of the distant end of the lumen. This scope was one that had been in use for several years and had been sterilized. On further investigation, we found that due to the structural design of the device, it was extremely difficult to visualize the internal lumens. A special camera was borrowed and the scope was internally visualized. We found a design flaw with a divot that couldn’t be cleaned well even with a brush, rust particles present internally within the lumen! We inspected all of the scopes we had in this design and found the same issues in varying degrees.

A statewide stakeholder meeting was held with safety and quality and the risks assessed. After an extensive consultation TGA was notified and all scopes in this design across the state pulled from use and reviewed. The risks to the patients were extremely low, so no contact training was undertaken.


This highlighted how important our CSSD services are in cleaning and reprocessing devices. It gave us challenges, opened up debate about solid scope designs, and how do you assess a new piece of equipment like this in future.


Marija Juraja RN, Grad Cert IC, CICP-E

Marija has previously held the position of President of the Australasian College for Infection Prevention and Control (ACIPC), including state and national appointments to the Healthcare Associated Infection’s Implementation Advisory Committee at the Australian Commission on Safety & Quality in Health Care and Joanna Briggs Institute (JBI) Infection Control Node Expert Reference Group. She currently is co-Chair of ACIPC Conference Committee and a contributing member of ACIPC Policy Committee.

Marija also works in the position of Nurse Unit Manager for Central Adelaide Local Health Network, Infection Prevention and Control Unit. She holds an adjunct teaching position at The University of South Australia. She has published and co-authored several articles and guidelines and presented at both national and international conferences.

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