Monday, June 13, 2005

Not Very Slick Management: Administrators Alleged to Ignore Surgical Instruments "Disinfected" with Used Hydraulic Fluid

From the Associated Press, via the Charlotte Observer, came the story that a mix-up at Duke Health Raleigh and Durham Regional hospitals, both run by the Duke University Health System, caused surgical instruments used for operations on 3800 patients to be "disinfected" by immersion in hydraulic fluid drained from a hospital elevator system, rather than detergent.
According to the version reported in the Raleigh News and Observer, operating room staff complained to administration that their instruments were covered with oil. Sometimes, the staff had to wipe down tools because they were too slick to be usable. However, according to a Center for Medicare and Medicaid Services (CMS) report, "Administrative staff failed to heed the multiple complaints of staff sterilizing and using the instruments, thus delaying the discovery of the error and needlessly exposing patients to these instruments over a longer time period." So far, Duke has refused to reveal results of analyses of the content of the used hydraulic fluid. Duke officials declined interviews, but insisted that the surgical infection rate has not increased since the mix-up. A patient who suffered various maladies after surgery with the oily instruments requested information about the exposure from Duke, but received a letter from its risk-management department stating, they were "not in a position to respond at this time."
Not such slick managerial work on this one... Sorry, I couldn't help making these terrible puns, but sometimes we try to laugh to keep from crying. This story is so bizarre that it sounds like an urban legend. What kind of hospital manager would ignore repeated reports that surgical instruments came out of the sterilizer coated with oil? But with 422 related posts on Google News by June 14, this story appears all too real.


Cetona said...

As a Duke graduate, I'm sad to report that the bizarre stories of oil-coated instruments surprise me not in the least.

There have always been two uneasily coexisting cultures at Duke. There is the "high culture of science," supported by a bureaucracy of R01 production. Then there is the "culture [I will resist using terms like 'low'] of hospital commerce."

The latter is so highly layered, stratified and stultified that I'm reminded--here comes my other Duke doctorate, in history--of nothing so much as the medieval church. "What, you want to talk about evidence the earth isn't at the center of things. Nope, that's not the way we do things around here."

Sorry, me goode olde alma mater. Guess I won't get that long-awaited request for a spot on the Board of Trustees!

Anonymous said...

I am writing to you as a "Hydraulic Fluid Victim". I'm very pleased to see that someone has taken a little interest in our situation and at least question the integrity of Duke's protocol. As small as it may's something.

I have been extremely infected (yes, I did use the word infected) by the arrogance of this institution and by the road blocks they've placed in my way. I'm not just concerned about my future and what is going to
happen to me.......I know what it's doing and without going into the sorted details, I'm one sick lab rat. The used Hydraulic Oil that I was "minimally" exposed to has altered mine and my family's life forever. No one can tell me how or when this will pass or the effects
I'll have after I've been pickled by the lead, arsenic,
organophosphates, mineral oil and the other metals that "couldn't possibly" harm me. I'm not looking to the future as I take each day as it comes and with each new day comes a different obstacle to overcome. I'm not here to have a pity party,(it's just not me) I'm wanting the
world to know that people are very ill and that all I've ever wanted is to get back to the world I came from before walking into the hospital from hell.

So, I'm just wondering why it is that if this "crap" had been spilled in an industrial accident, say for instance by a train, in a family neighborhood wouldn't the EPA and the government be cleaning up the site and making sure it didn't endanger the wildlife, drinking water or the human population? For example, In February 2005, 125,000.00 lbs of meat was recalled due to Hydraulic oil contaminating it. Now mind you, this is meat you cook, digest and is not injected under the skin to fester. The FDA came down on the perpetrators and made them stop selling this enormous amount of meat. Can you imagine the lost revenue? I'm sure Duke can! So, why is it that they can get away with a monumental "mistake" of this nature and not be held accountable to someone other then the legal system? Why is it that the medical community isn't up in arms about the lack of accountability? You all as doctors wonder why us as patients distrust you......this is why!

Has anyone ever heard of the "Power of an apology"? I know Duke hasn't.

What is wrong with our society when lab animals have supporters in Washington but an institution can poison unsuspecting patients and we have no voice or defenders? We NEED HELP! SOS!

Anonymous said...

What is really, really bad is that I got exposed having a c-section, now my obgyn says he is not sure if it is safe for me to have another baby. This is really not fair to my daughter, she may never have a brother or sister. She may not even grown up with a mother if the exposure kills me prematurely. I have all kinds of symptoms, people that are 10-20 years older than me are in better health, they have more energy, and don't have the problems I have been having: from skin rashes, headaches, muscle aches, and pain at my scar. My arm may not fall off today or tommorow, but the long term effects from this exposure is sure to have shortened my lifespan. Just because you can't see pain doesn't mean it doesn't exist. It saddens me, it frightens me, and DUKE won't even say they are sorry. BASTARDS!