Surgical Tools Washed In Hydraulic Fluid At Duke Hospitals

[mac23]

: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.

[mac23]

Although I did post this I'm not Duke bashing. I used to work there and my sister is a bone marrow transplant patient there now who's had consultations with both the pulmonary and cardiac docs and I have to say they have been outstanding, imo, compared to some of the other places we've been in preparation for her transplant. The hospital isn't perfect by any means, what hospital is, but in some areas they absolutely deserve the reputation they have as one of the best. We are forever indebted to the hem/onc and bone marrow transplant folks at Duke and given the same situation, I think we'd make the same decision to come to Duke for treatment.

[Brickman]

Excuse me, but I work on the pulmonary unit of Duke hospital and I happen to thing that we do a darn good job. By the way our "average" pulmonary unit is the only unit on the east coast that you can receive Flolan for the treatment of Primary Pulmonary Hypertension, we also manage adult CF, COPD, asthma, S/P ARDS, pulmonary fibrosis, sarcoidosis, we also manage long term and difficult weaning from the ventilator. We also get extremely rare diagnosis such as ciliary dyskinesia and Wengers .

We do all that including Flolan (except for vents) right down the street at UNC Hospital 6 Bedtower. We also are the infectious disease unit. Where did you get the idea that Duke was the only place on the east coast to receive Flolan? While Flolan does have it's own unique protocols I can't beleive it is that rare on the east coast.

[Nurseboy1]

We do all that including Flolan (except for vents) right down the street at UNC Hospital 6 Bedtower. We also are the infectious disease unit. Where did you get the idea that Duke was the only place on the east coast to receive Flolan? While Flolan does have it's own unique protocols I can't beleive it is that rare on the east coast.

That's what my NM said during orientation. We also get multiple out of state admissions for initation of Flolan. I wasn't intending on putting any other unit down, the earlier poster simply angered me by what she had to say about pulmonary care at Duke. I don't speak for other hospitals or other units because I don't work there.