HN Summary

•Issue: Hard water caused sterilization failures, disrupting surgeries.

•Response: Emergency surgeries protected; instruments sent to Vancouver for sterilization.

•Outcome: 165 surgeries postponed, services restored, new safeguards underway.

When a sterilization failure forced the cancellation of 165 surgeries at Whitehorse General Hospital earlier this year, the disruption exposed how a single system failure can ripple across an entire hospital—and how resilience, teamwork, and transparency can help restore services.

Between late January and early April, surgical services at the Yukon’s largest hospital were dramatically reduced after instruments emerged from sterilizers with residue and staining, making them unsafe for patient use. Cataract surgeries were hit hardest, with 135 cancelled, while joint replacement and laparoscopic procedures were also affected. Emergency surgeries, however, continued without interruption.

Swift response under pressure

From the outset, hospital leaders and staff placed patient safety at the centre of every decision. “Our priority was clear: protect patients while we found a safe solution,” said Tiffany Boyd, CEO of Yukon Hospitals.

The hospital quickly activated an Incident Command Structure, drawing on expertise from engineers, infection control, and external consultants. By February 7, a partnership with Vancouver General Hospital allowed for off-site sterilization, while a stopgap hand-wash protocol with bottled reverse osmosis (RO) water enabled limited services to resume.

By February 10, some surgical procedures were back online, though capacity remained limited for several weeks.

The root cause: water quality

The underlying issue, confirmed by an independent expert review in late March, was the use of “utility water” rather than “critical water” during the final washing of instruments. Whitehorse’s naturally hard water compounded the problem, causing the residue and tarnish.

The report found that existing infection-control checks worked as intended—spotting unsafe instruments before they reached patients—but the hospital’s sterilization infrastructure required urgent upgrades.

Recovery and resilience

By early April, with new protocols in place and system fixes underway, sterilization resumed at Whitehorse General. On April 7, the hospital announced that full surgical capacity had been restored.

For frontline staff, the experience was intense. “Every day we walked into the OR not knowing if we’d have the tools we needed,” said Karen Mitchell, RN, operating room nurse. “But we trusted each other, adapted quickly, and kept patients at the centre of our decisions.”

In the Medical Device Reprocessing (MDR) department, the pressure was just as heavy. “We knew the eyes of the whole hospital were on us,” said David Chen, sterile processing technician. “It was stressful, but it also showed how critical our work is. Without sterilization, the OR can’t function.”

Since the incident, Yukon Hospitals has committed to long-term improvements: installing deionization and ultrafiltration systems to ensure reliable water quality, strengthening preventive maintenance schedules, and expanding its stock of surgical instruments to minimize future disruptions. A new MDR department, designed to meet updated national standards, is also in planning.

Lessons for other hospitals

While the crisis was localized to Whitehorse, its lessons resonate broadly. Hospitals across Canada rely on often-invisible infrastructure like sterilization, water, and steam systems to keep surgeries running safely.

“Redundancy and proactive planning are key,” Boyd emphasized. “This incident reinforced how essential it is to have backup processes, to invest in infrastructure, and to remain transparent with patients and staff.”

Looking ahead

All patients whose procedures were postponed have now been rescheduled, and officials say the hospital has emerged stronger and better prepared.

Across Canada, the incident is a reminder that while hospitals often prepare for clinical crises, technical and infrastructure failures can be just as disruptive—and just as important to plan for.

As Boyd put it: “We owe it to patients, families, and staff to learn from this and to make sure we are better prepared for the future.”

Timeline: Whitehorse General Sterilization Incident

• Jan 31, 2025 – First signs of staining and residue on sterilized surgical instruments; surgeries suspended for safety checks.

• Feb 3 – Issue recurs after initial fixes; elective surgeries cancelled.

• Feb 5 – Incident Command Structure activated; outside experts called in.

• Feb 7 – Agreement reached with Vancouver General Hospital for off-site sterilization; endoscopy resumes.

• Feb 10 – Some surgical services restart under new protocols.

• Feb–Mar – Extensive testing and troubleshooting of washers, autoclaves, water, and steam systems. Additional instruments acquired.

• Mar 20–21 – Independent review identifies water quality as the root cause; recommendations provided.

• Apr 3 – On-site sterilization safely resumes.

• Apr 7 – Full surgical services restored at Whitehorse General.