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.

[Marie_LPN, RN, LPN, RN]

Yuck, yuck, YUCK.

[kellyo, LPN]

Oh yeah. It was nice to open my local paper and see that story glaring at me from the headlines...

[VickyRN, MSN, DNP, RN]

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?

[Marie_LPN, RN, LPN, RN]

Work oughta be fun on Monday.

[CarVsTree]

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]

Didn't anyone notice the lack of soap suds????

[begalli]

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.

I think a thing to remember to look for with these types of reports is the number of cases a particular hospital takes compared to other hospitals and that some hospitals such as Duke probably take the sickest of the sick who probably have slim chances of survival to begin with.

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]

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?

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.

[VickyRN, MSN, DNP, RN]

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 :)

[Nurseboy1]

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').

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 granulamatosis and lupus. The PICU fire was caused when they were hooking a child up to ECHMO, the cautery tool ignited the drapes and the fire was immediately extinguished with sterile water. The child was not injured in any way. I really do take offense to your judgement of my unit when you don't live in this state, and you've probably never even been to my facility.

I don't work on the cardiac unit so I can't speak for them.

[chris_at_lucas_RN, RN]

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.