Goshen Health update

November 20, 2019

Recently, the leadership at Goshen Health became aware of a situation that may have impacted a small portion of our surgical patients only at Goshen Hospital from April through September 2019. During this time, one step in a multistep cleaning process was missed for some specific surgical instruments by one of our seven sterilization technicians.  
Our priority is always the well-being of the communities we serve. In this case, we missed the mark and fell below our high standards. This is not acceptable. We are committed to getting it right and ensuring that safety and quality processes are in place so that these mistakes do not occur again.
When the error was discovered, a cross-functional team of medical professionals was immediately convened to do a root-cause analysis and bring back recommendations. That team took action immediately to correct the problem while identifying processes, policies and safety measures to ensure it does not happen again. This included purchasing additional technology used in only a subset of hospitals across the nation, that further reduces the potential for human error.

As we investigated the details of this event, our team discovered a beginning step in our sterilization process was omitted by a single technician for a small subset of surgical instruments. These instruments were still treated by the rest of our cleaning and sterilization process. This included enzymatic cleaners (chemical), machine washer disinfection and/or ultrasonic cleaner process, and also high steam temperatures and pressure for a long period of time. 

These sterilization processes provide a wide margin of safety and significantly reduce risks for patients.  At the same time, since one step in the process did not occur, we needed to make sure that no problems resulted and no patients were harmed. 

While our sterile processing and infectious disease experts believe that the potential transmission of blood borne viruses between patients is extremely remote, out of an abundance of caution, we want to verify through lab blood tests that patients have not been harmed. We elected to cast a wide net to inform via letter all patients that may have been affected while offering free testing to ensure everyone’s safety. 
If a Goshen Health patient did not receive a letter, it means they were not impacted. This issue was isolated to a small subset of our patients that we have notified directly, and other surgical patients during this time frame are not at risk. If you are concerned you should have received a letter, please call our call center at (574) 364-2100.
For those patients that are involved, we have taken steps to set up a Goshen Health call center to answer questions and schedule testing. We want to be responsive to questions and concerns, and there are no costs for these screenings.
The call center can be reached at (574) 364-2100, Monday through Friday, 8 a.m. to 4:30 p.m. Should you need to call outside of these hours please leave a message for how you can be reached on the secure voicemail system and a Colleague will promptly reach out to you the next business day.
We are encouraged by the number of patients calling and getting screened. If you received a letter, we encourage you to call our call center and schedule a screening. Published studies from other situations around the country note a response rate typically around 7% from patients being notified with many choosing to not get tested when these issues occur. We are grateful for the engagement and support of our Goshen patients.
As Chief Executive Officer and Chief Medical Officer, we want to apologize for what occurred and the worry and anxiety this situation has caused. While the testing and communication goes beyond what may be needed, we want to take every precaution to ensure the safety and well-being of our community.
When we make a mistake, we want our community to be confident that we will not hide from our failure, but take action to correct the error and ensure that it does not happen again. We are committed to the safety and comfort of our patients and their families. 
Thank you for your continued support and engagement with us as we work to make this right. 


Randal E. Christophel, MBA, FACHE                                                   Daniel A. Nafziger, MD, MS
President and Chief Executive Officer                                                 Hospital Chief Medical Officer