Contaminated surgical tools found in Grande Prairie operating room in April, AHS records show

Contaminated medical instruments found their way into an operating room at the Grande Prairie Regional Hospital (GPRH) on at least two occasions this year, according to Alberta Health Services’ meeting notes that were acquired by CBC News via an Access to Information and Privacy request.

Their discovery postponed some surgeries at the hospital, while using steam to sterilize surgical equipment was outsourced to Edmonton during the spring.

The documents, which include meeting notes, memos and surgery cancellation data, said a similar incident happened about  two years earlier.

The incidents show gaps throughout the sterilization process and across multiple teams, the documents state, “including surgeons, operating room staff and Medical Device Reprocessing (MDR).”

Meeting notes identified instances on March 10 and April 15 where dirty medical instruments were found following the sterilization process.

During the March 10 incident an orthopedic instrument “contained a retained guidewire and visible tissue from a previous case” after the cleaning process.

Another orthopedic instrument with retained tissues was discovered during a surgery on April 15. The instrument had not been used during the procedure, but the meeting notes said “another instrument from the same contaminated set was used to complete the surgery.”

Elective surgeries were postponed on April 16.

It’s indicative of a serious problem in the quality of the reprocessing.– Dick Zoutman, retired infectious disease specialist

Although the documents did not state what kind of “retained tissue” was found on the instruments, Ontario-based retired infectious disease specialist Dick Zoutman told CBC News that finding dried blood, bone fragments, tissue,  dried cement or water spots on instruments can occur when the MDR process fails.

“That’s not supposed to be there and shouldn’t ever happen. It’s indicative of a serious problem in the quality of the reprocessing,” said Zoutman, who previously worked as chief of staff in two different Ontario hospitals.

Zoutman said orthopedic instruments can be complex pieces of machinery that involve gears, ratchets and other moving parts that require intricate cleaning. He also said there is no excuse for them not being properly reprocessed.

“They were very careful and did the right thing,” Zoutman said of the scrub nurse who found the contaminated tool during the April 15 procedure.

“That’s a very good thing to keep the patient safe. However, it shouldn’t have happened in the first place. There should have never been debris on these instruments.”

An AHS spokesperson told CBC in a Aug. 7 email that mandatory cleaning, disinfection, sterilization and documentation take place during that reprocessing process. 

“AHS follows rigorous Medical Device Reprocessing (MDR) standards and Infection Prevention and Control (IPC) practices,” the spokesperson said.

“If a device does not meet these standards at any point, it is removed from service and investigated. Established protocols also require patient notification and testing where warranted.”

An incident briefing note shows a MDR support-team from Edmonton was deployed to the hospital on April 21. Local steam sterilization was halted and moved off-site the following day after packs of instruments were found to be still wet after going through the sterilizers.

Sterilization resumed in Grande Prairie in June.

An AHS spokesperson confirmed in an Aug. 7 email to CBC that “no patient infections have been identified, and no additional MDR breaches have been identified at GPRH since April 2026.”

Some practices halted at GPRH

Meeting notes dated April 14, showed that “a number of concerning practices were identified” in relation to MDR procedures at the hospital during that period. 

“Several MDR practices were identified as requiring further education and clarification,” the notes said.

The documents noted MDR dress codes were not being consistently followed. An open drink in a sterile storage area was found. Instruments were not always cleaned immediately at the bedside. Instead, the documents said they were sometimes sprayed with cleaner then transported in bins for further sanitization.

The meeting notes revealed that several practices were halted, such as using white erasers at workstations to remove water spots and keeping brushes at assembly stations, to ensure proper sanitation was completed during all steps.

The AHS statement said patient safety is a top priority and any potential lapse in sterilization is taken extremely seriously.

As of July 20, AHS said 97 per cent of postponed surgeries had been either completed or re-scheduled.

“GPRH has resumed regular surgical activity, with more than 130 elective surgeries scheduled weekly. On-site instrument reprocessing continues through a mobile MDR unit while permanent infrastructure repairs and upgrades are completed,” said the statement.