Hospital crisis management concerning a distilled water contamination accident

• Published in: The Journal of Japan Society for Health Care Management Vol. 7; no. 4; pp. 525 - 529
• Main Authors: Matuura, Koubun, Kaneko, Hiroyasu, Maekawa, Kazuhiko
• Format: Journal Article
• Language: Japanese
• Published: Japan Society for Health Care Management 01.03.2007
• Subjects: comamonas; distilled water bacterial contamination; hospital crisis management
• ISSN: 1881-2503; 1884-6807
• DOI: 10.11191/jhm2006.7.525

We studied the correspondence of the hospital crisis management to a bacterial water pollution accident at the Kanto Central Hospital of Mutual Aid Association of Public School Teachers. A periodic routine testing of the distillation system taken from the outflow ports17days after an overhaul of a distillation device in the pharmacy revealed bacterial contamination of specimens. Within2hours after notification from the laboratory the hospital's emergency management committee was summoned and headquarter was set up. A list of patients in whom the distilled water was used during the preceding 17days was prepared and a problem “tree” according to the water usage was drawn up with the gathered information and as well as a patient information sheet. The distilled water in question was used for dilution of liquid oral medications in30outpatients and22inpatients. The patients/families were contacted over the phone by physicians and the situation was explained with an official apology according to the prepared position paper in addition to collecting the particular medicine and supplying an alternative one. Comamonas, a non-fermentable bacteria of environment origin, was identified the next day as polluting specimen. After making an appointment, a team of a director or deputy director, a pediatrician/obstetrician and an administrative official visited the patients' homes over the next two days. During each visit inquiries were made into the patient's health and concerns, and a stool culture examination at the hospital's cost was proposed. In all28patients' homes were visited. None of the44patients who had taken medications with the distilled water in question turned out to have any health problems. Managing a hospital crisis like this one mandates prompt establishment of the emergency management headquarter, intensive information gathering, efficient countermeasures, and an organized response by mobilizing all people concerned.