Duke Univ. surgical tools contaminated [washed in hydraulic fluid]

RALEIGH - Over two months last year, 3,800 patients at two hospitals run by Duke University Health System were exposed to surgery with instruments that were washed in hydraulic fluid instead of detergent, hospital regulators say.

Duke Health Raleigh (formerly Raleigh Community) 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, the regulators said.

The hospitals did not fix the problem for weeks, said the report from the Centers for Medicare & Medicaid Services, which The News & Observer of Raleigh reported Sunday.

"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," said the report from the agency, which oversees patient care at hospitals that receive payments from federal insurance programs.

When Duke Health officials disclosed the mistake in January, they assured patients that the likelihood of infection was "no more than the risk normally associated" with the procedures patients underwent.

But seven months later, dozens of patients who were exposed to the surgical instruments are reporting lingering health problems -- some minor, such as fatigue and joint pain, and others serious, requiring hospitalization, the newspaper said.

Within days, according to the investigation, staff members at the affected hospitals began complaining about greasy instruments that often left an oily yellow stain on the tray liners. On some occasions, the operating room staffs wiped down the tools with sponges because they were so slick, investigators reported.

Many patients say they have asked Duke to tell them what was in the used hydraulic fluid, a petroleum product called 32 AW manufactured by Exxon that may have picked up particles from its use in the elevator.

Luanne Williams, a state toxicologist, said other substances might have been introduced during the fluid's use in the elevator, giving it a unique chemical composition.

In response to patient requests about what was in the used hydraulic fluid, Duke has said it's still investigating and can't provide such details yet.

Duke Health System officials declined to be interviewed, the Raleigh newspaper reported, citing possible lawsuits.

They issued a short statement reiterating that infection rates are not notably higher than would typically be expected, and urging patients to talk with their doctors about concerns.

Thomas Henson Sr., a lawyer representing eight patients, said he is exploring whether to file a legal petition demanding that Duke reveal the contents of the hydraulic fluid.

"If Duke doesn't have anything to hide, why are they hiding it?" Henson said. "Give me the scientific evidence that says these people are not at risk. "

More here........

Duke slow to find fluid error

Dozens of patients at two Duke Health System hospitals say problems linger after surgery

[snip]

Anatomy of a mix-up

According to the investigation reports, the mix-up originated last summer when an elevator at Duke Health Raleigh was repaired.

The inspectors said that workers drained hydraulic fluid from the elevator into about a dozen empty detergent drums that they got earlier at Duke University Hospital when they fixed an elevator there.

Most of the 15-gallon drums were marked "Mon-Klenz," the brand name of detergent used to wash surgical tools; one was an empty drum that had contained a lubricant for hinged instruments, and it was labeled "Hinge Free."

Inspectors said the repairs at Duke Health Raleigh ended in September, but the drums remained in a corner of a parking lot until a hospital administrator ordered them removed. Staff members, thinking the containers held detergent as labeled, called Cardinal Health, the detergent supplier, and had them picked up.

According to the investigators, Cardinal Health took the drums to its warehouse, not suspecting that the fluid was anything other than Mon-Klenz (the hydraulic fluid and the detergent have a similar maple-syrup color). When the hospitals ordered detergent in November and December, the company shipped the tainted barrels -- one drum to Duke, three to Duke Health Raleigh, five to Durham Regional and two to Wake Forest University Baptist Medical Center in Winston-Salem.

The barrels sent to Duke and Wake Forest were not used, a spokesman at the state Department of Health and Human Services said.

Inspectors' report

Inspectors said the drums were not sealed properly but were "accepted without question" by hospital workers, then hooked up to the washing machines at Duke Health Raleigh and Durham Regional. Within days, according to the investigation reports, staff members at both hospitals began complaining about greasy instruments that often left an oily yellow stain on the tray liners.

The complaints continued through November and into December, with numerous attempts made to fix the washers. But investigators said no one checked to see if the right detergent was being used until late December -- even though a trouble-shooting guide for the washing machines recommended checking the detergent if tools come out unclean.

Talk about a Sling Blade moment..........."There ain't no gas in it......."

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