Nurses General Nursing
Published Jan 8, 2005
mac23
107 Posts
:uhoh21:
Surgical Tools Washed In Hydraulic Fluid At Duke Hospitals
POSTED: 8:59 am EST January 7, 2005
UPDATED: 3:56 pm EST January 7, 2005
DURHAM, N.C. -- Workers at two hospitals affiliated with Duke University Health Systems accidentally washed thousands of surgical instruments with hydraulic fluid instead of detergent during November and December.
Hospital officials said they have received no reports of medical complications resulting from the mix-up.
Durham Regional Hospital and Duke Health Raleigh Hospital, formerly Raleigh Community Hospital, have sent letters to nearly 4,000 patients to notify them about the substitution of the look-alike fluids. Hospital officials believe the risk is "very, very low," but that patients are being contacted as a precaution, Durham Regional chief executive officer David McQuaid said.
The hydraulic fluid is a petroleum product that the U.S. Environmental Protection Agency does not consider hazardous, said Wayne Thomann, a Duke occupational safety specialist.
Workers from an elevator service company, Automatic Elevator, apparently drained the hydraulic fluid into empty, 15-gallon detergent containers while working at Duke Health Raleigh, then replaced the caps without re-labeling the containers, hospital officials said.
Jim Mazzola, a spokesman for the detergent supplier, Cardinal Health Inc., of Dublin, Ohio, said his firm and Duke officials still were determining how the containers wound up in the wrong place.
"We're working with them to try to understand how these containers came to be inappropriately refilled and returned to us," he said. "But it appears the product containers were returned to us by Duke in October. It was properly labeled, so we re-stocked it. Then Duke placed a new order for it, so we shipped it to them."
The problem was discovered when someone noticed an unusual oily residue on surgical instruments like scalpels, forceps and scissors coming out of the facility's three washing machines, Durham Regional spokeswoman Katie Galbraith said.
The wash cycles precede a high-temperature steam sterilization that kills potentially harmful bacteria and viruses, said Keith Kaye, a Duke physician and co-chair of the Duke Infection Control Network.
There's no danger that anybody could contract HIV, hepatitis or any other communicable disease from the mix-up, he said.
"We haven't seen notable increases or any other adverse events reported by patients at either hospital since this problem arose," Kaye said.
Marie_LPN, RN, LPN, RN
12,126 Posts
Yuck, yuck, YUCK.
kellyo, LPN
333 Posts
Oh yeah. It was nice to open my local paper and see that story glaring at me from the headlines...
VickyRN, MSN, DNP, RN
49 Articles; 5,349 Posts
Wow, this is the third majorly bad story I've heard within the past year or two coming out of Duke... the other two, of course, being the tragic transplant mix-up and the child burned in the PICU. What gives?
Work oughta be fun on Monday.
CarVsTree
1,078 Posts
I'll tell you what. If you look on http://www.healthgrades.com you can see that Duke is NOT where you want to go if you have cardiac or pulmonary problems. They rated average to poor in almost every procedure.
Did they ever figure out the PICU fire? Hydraulic fluid is petroleum based, which is highly flammable in an oxygen environment - respiratory tells us never, never use petroleum and oxygen together (i.e. no vaseline on lippys with nc's goin').
gwenith, BSN, RN
3,755 Posts
Didn't anyone notice the lack of soap suds????
begalli
1,277 Posts
I'll tell you what. If you look on www.healthgrades.com you can see that Duke is NOT where you want to go if you have cardiac or pulmonary problems. They rated average to poor in almost every procedure.
Duke was ranked 3rd in heart and heart surgery in US New's 2004 Best Hospitals.
This most recent problem at Duke is very disturbing.
Nurseboy1
294 Posts
Vicky for the record the incident occured at Durham Regional and Duke Health Raleigh hospital. The elevator workers violated the law by placing the fluid in a container designated for another purpose.
Thanks for the clarification :)
I'll tell you what. If you look on www.healthgrades.com you can see that Duke is NOT where you want to go if you have cardiac or pulmonary problems. They rated average to poor in almost every procedure.Did they ever figure out the PICU fire? Hydraulic fluid is petroleum based, which is highly flammable in an oxygen environment - respiratory tells us never, never use petroleum and oxygen together (i.e. no vaseline on lippys with nc's goin').
I don't work on the cardiac unit so I can't speak for them.
chris_at_lucas_RN, RN
1,895 Posts
This is pretty interesting, in a bizarre sort of way, especially in light of the fact that hydraulic fluid is usually oil (as in petroleum product) based.
Never have seen a detergent that wasn't soapy.
Hmmmm.