District Health Boards (DHBs) are continuing to expose patients to unsterilised equipment.
Documents obtained by Newshub show at least 25 patients have been exposed to unsterilised equipment since March 2019.
Southern DHB is responsible for 19 of them, Taranaki DHB and Tairawhiti had two each, Wairarapa had one while there is one possible case in Auckland.
There's been an incident in Bay of Plenty too, but the DHB isn't sure how many people were affected.
"It's quite disturbing because we aim as a professional group to give every patient the same level of care. For us as professionals, as I say, is never acceptable," says New Zealand Sterile Sciences Association president Shelagh Thomas.
In a statement, Southern DHB said a number of incidents were related to surgical cement, hair and water found on the instruments or instrument tray. The DHB says it has a highly dedicated sterilisation team. However, that team is forced to work in a cramped space that isn't fit for purpose, which makes it challenging. It says a new facility should be completed in Dunedin next year.
"What I do want to know is that when there is a failure of sterilisation of equipment patients are kept under surveillance and any risk of infection is properly dealt with," says Health Minister Andrew Little.
All DHBs have made assurances no patients were harmed. But Thomas warns it can pose a risk.
"If you have dirt on an instrument, even if it's been through a steriliser it still has the potential to cause a reaction in a patient."
Part of the problem is only eight of the 20 DHBs use an electronic tracking system for reusable medical devices. The rest use paper-based systems.
Newshub has seen a leaked email from one medical professional who says with those systems there's often no way of knowing what equipment has been used, and where. They also say their sterilisation department is managed by people who don't have relevant qualifications or experience. Therefore they're not giving the patient the best possible care by providing them with properly cleaned and sterilised equipment.
The Ministry of Health says it's working with DHBs to update sterilisation guidelines and is following up to ensure appropriate tracking systems are in place.
"This must be seen as a component of the entire quality assurance process which the Ministry is well advanced in closing the quality loop on."
