Report: Surgical tools at hospitals were washed in hydraulic fluid, not detergent | San Diego Tribune | 6.13.05
RALEIGH, N.C. – About 3,800 patients at two hospitals run by Duke University Health System were operated on last year with instruments that were washed in hydraulic fluid instead of detergent, hospital regulators said.
Duke Health Raleigh and Durham Regional hospitals put patients in “immediate jeopardy” in November and December by not detecting the problem, despite complaints from medical staff about slick tools, according to a report by the Centers for Medicare & Medicaid Services.
The hospitals did not fix the problem for weeks, said the agency, which oversees patient care at hospitals that receive payments from federal insurance programs.…
However, dozens of patients who were exposed to the surgical instruments have reported lingering health concerns ranging from fatigue and joint pain to problems requiring hospitalization, the The (Raleigh) News & Observer reported Sunday.
At least 50 patients who developed complications have taken their concerns to lawyers, though no one has sued Duke or the hospitals. Two lawsuits have been filed against the elevator company and the detergent supplier.…
Duke Health officials declined to comment further, citing possible lawsuits.
Surgical tools cleaned improperly | News & Observer | 1.7.05
Hydraulic fluid inadvertently used by two Duke hospitals
The letters to patients were sent Tuesday and Wednesday. Katie Galbraith, a spokeswoman for Durham Regional, said the hospital already has had more than a dozen calls from concerned patients.
They should have nothing to worry about, said Dr. William Rutala of Chapel Hill, an expert on disinfection and sterilization at UNC.
“Steam sterilization is an extraordinarily robust process,” Rutala said in an interview. “You can do a lot of things wrong and still have a sterile instrument.”
Patients treated at Duke Health Raleigh Hospital between Nov. 4 and Dec. 30 might have been exposed to the instruments. The same goes for Durham Regional patients seen between Nov. 24 and Dec. 22. Patients would not have been exposed unless they had a body-invasive procedure, such as surgery or catheterization.
Dr. Keith Kaye, director of infection control for the Duke health system, said rates of infection among patients treated at the two hospitals are being monitored. So far, the system has seen no increase, he said.
The hospitals have asked patients who notice any signs of infection, such as fever, pain or redness at the site of the incision, to notify them.…
Parsing the mistake
The hospitals are working with Cardinal Health, the Ohio company that supplies the Duke health system with detergent and other hospital supplies, to understand how the mistake happened.
The health system has determined that a Durham elevator company, Automatic Elevator, emptied hydraulic fluid into several empty detergent drums while performing maintenance at Duke Health Raleigh Hospital in mid-September, said Carla Parker Hollis, a hospital spokeswoman.
Automatic Elevator confirmed the hospital’s explanation.
Apparently, those drums then were mistaken for surplus stock and returned by the hospital to Cardinal Health. Cardinal Health later redelivered the same drums to the two hospitals, said Jim Mazzola, a spokesman for Cardinal Health. “Our next step is to understand how this happened,” he said.
Hospital employees initially didn’t notice anything amiss because the hydraulic fluid and the detergent are both odorless and about the same color, Parker Hollis said. Even an oily residue on the instruments was not terribly unusual, because they are routinely treated with a lubricant to prevent rusting.…
Hydraulic Fluid Injury | White & Stradley, LLP
Duke Health Raleigh and Durham Community Hospitals
In the fall of 2004, surgical instruments at Duke Health Raleigh Hospital (formerly Raleigh Community Hospital) and Durham Regional Hospital were contaminated with USED HYDRAULIC FLUID. The hospitals used the contaminated instruments in surgical procedures from approximately October to December 2004. Patients exposed to the contaminated instruments should have been notified by Duke University Health Systems, the operator of both hospitals involved.
White & Stradley, LLP is in the process of investigating this incident. Our preliminary investigation has revealed that the hydraulic fluid likely contained dangerous material including, PCBs and heavy metals and may have contained dioxins. The extent to which these chemicals were present on the contaminated instruments in currently unknown. Additionally, the number of post-surgical complications appears to be higher than normal among patients exposed to the contaminated instruments. White & Stradley, LLP represents a number of persons exposed to the contaminated instruments.
IF YOU HAVE BEEN EXPOSED TO CONTAMINATED SURGICAL INSTRUMENTS AT DUKE HEALTH RALEGH OR DURHAM REGIONAL HOSPITALS, contact White & Stradley, LLP…
“[P]ossible lawsuits” and “likely contained,” you just got to love those qualifiers.