EXECUTIVE SUMMARY
Physicians at Detroit Medical Center complained that surgical instruments were unclean, missing, and damaged for 11 years without resolution of the issue. One surgeon used duct tape more than once to repair broken instruments. Hair, bone, and dried blood were found in instruments. Four hundred missing brushes were found in a sterile technicians’ locker.
- Complaints regarding instruments should have been documented and gone to the medical director, risk management, quality improvement, the head of nursing, and the board.
- Having a vendor teach might help improve infection training. File training content and materials with the sign-in sheets.
- Trailing the person who oversees a hospital’s central sterile processing can be helpful.
“It’s a surgeon’s nightmare.” These words, spoken by a physician at Detroit Medical Center (DMC), ran in The Detroit News in a multi-story investigative series about how physicians had reported unclean, missing, and damaged surgical instruments for 11 years without the issue being resolved.
One surgeon told the newspaper he had used duct tape more than once to repair broken instruments during surgeries. The newspaper also reported hair, bone, and dried blood in instruments, as well as instruments covered in blood. When sterile technicians’ lockers were searched at one hospital that is affiliated with DMC, 400 missing brushes were found, as well as a large number of supplies and instruments that had been missing. (See our story, “Are staff stealing your supplies and selling them on the Internet?” Same-Day Surgery, August 2010, at http://bit.ly/2daHu8H.)
A risk manager interviewed by SDS had a response similar to the DMS physician regarding the ongoing issues with instruments. “I am floored by this,” says R. Stephen Trosty, JD, MHA, CPHRM, ARM, risk management and patient safety consultant in Haslett, MI. He described the reports as resembling scenes from a horror movie.
The result has been negative publicity and a complaint-driven state survey that found multiple violations at the hospital system, which previously earned many national awards for high-quality care.
The Central Sterile Processing (CSP) Department in the basement of Detroit Receiving Hospital’s Midtown campus is responsible for services at four licensed hospitals on the DMC central campus: Detroit Receiving Hospital, Harper University Hospital, Hutzel Women’s Hospital, and DMC Children’s Hospital. In reporting on the CSP services at these campuses, The Detroit News reviewed 200 pages of internal documents. Problems with surgical instruments compromised patient safety, extended or canceled surgeries, and complicated other cases, the newspaper reported. Some surgeries were canceled after anesthesia was administered, it said. It also said that some patients remained under anesthesia for up to one hour while instruments were replaced.
The series of articles quoted an email from Joseph Lelli Jr., MD, chief surgeon at Children’s Hospital, that read, “We are putting patients at risk frequently and now canceling up to 10 cases this week.” The email to administrators in June 2015 was at least his third warning over a six-month period, the newspaper reported. Over 17 months, there were 186 complaints about instruments that were dirty, missing, or incomplete at Children’s Hospital. (See story later in this issue about how such complaints should be handled.)
Most sterile processing managers strive for no more than 3.4 errors per million, according to the ECRI Institute in Plymouth Meeting, PA, which researches best practices in devices and medical procedures and was quoted in the newspaper series. The Detroit News reported that 95% of instruments were delivered without problems in June 2014, which equals about 50,000 errors per million instruments.
Trosty says, “If you present evidence to a jury, of this lax sterilization, the amount of time it went on, and knowledge of what the ramifications can be in terms of infection, I think you have an excellent chance of winning the case.”
The newspaper reported on an outpatient who had surgery at Harper University Hospital five years ago for scar removal. The woman developed a postoperative infection near the sutures and had to cancel plans for a 40th birthday party. She subsequently had nine operations to fix the infections and scars.
The woman was quoted as saying she is unable to work and is constantly in pain. She has hired an attorney. DMC declined to comment on the case reported by the newspaper, due to patient privacy laws, but it said it has not identified any safety issues or surgical site infections related to dirty surgical instruments.
The union leader representing DMC employees blames cost-cutting for the problem with instruments, according to The Detroit News. Specifically, the union leader said the hospital refused requests to buy more instruments and eliminated a system that conducted a second check of instruments to ensure they were clean.
The Detroit News reported that DMC was having problems with surgical instruments, such as a set of instruments not being delivered to the OR, even as it was undergoing a state inspection in February 2015. At Harper University Hospital, surveyors found that a wall that separated clean and dirty equipment was removed during construction, it said. Also, staff members entered the sterilization area without protective gear, and five other deficiencies were found, the newspaper reported. All of those deficiencies were addressed except one, which involved a floor that was being replaced, it said.
After the newspaper articles were published, the state administered a complaint-driven survey and found that DMC, through Detroit Receiving Hospital, was in violation of state standards. The hospital received eight violations for failing to ensure adequate training for sterilization workers.
The state said training sign-in sheets that were maintained by the hospital failed to include the content or materials.
“The CSP Department does not have a robust, consistent, repeatable, comprehensively documented, and well-maintained training system for new and existing employees and management,” the state report said.
A plan of correction must be submitted within 60 days. DMC is allowed to continue surgeries during this time, the newspaper said.
The primary problem at the hospital? A failure to employ high-quality managers for CSP, according to DMC’s Chief Administration Officer Conrad Mallett. One of the former directors of the sterilization department described the hospital’s situation as “a perfect storm” due to the volume, patient acuity, entry-level staff, and no “sustained support” from administrators.
Marcia Patrick, MSN, RN, CIC, a Tacoma, WA-based consultant, educator, and surveyor for the Accreditation Association for Ambulatory Health Care, says that cleaning and disinfection or sterilization often are performed by “the lowest paid, most poorly educated employees, and they may not understand the criticality of their jobs.”
In healthcare facilities, the supervision of these employees may be inadequate, Patrick says. “Central sterile functions are very complex, and attention to detail is essential,” she says. Minimally invasive surgical tools are much more complex and difficult to clean, the newspaper articles pointed out.
Some states are starting to require central sterile certification for employees, “which is a step in the right direction,” Patrick says. “Too often, one staff member trains another, neither having the knowledge and background to understand all the complexities and performance issues.”
Some facilities have partnered with local technical colleges for training employees for their jobs and the certification exam, she says.
In a “Message to the Community” from Suzanne White, MD, MBA, FACEP, FACMT, DMC’s chief medical officer, White said the hospital is “deeply committed to regaining the community’s confidence in this important department.” She shared that in June, the hospital contracted with United Health Trust to manage the CSP department. White also said the hospital had taken action including improved education and training/competency documentation. “We will continue working with our physicians and staff to improve CSP efficiency and performance while keeping our intense focus on patient safety at the heart of it all,” she said. (For tips on how to avoid dirty instruments in CSP, see the story later in this issue.)
REFERENCES
- Bouffard K, Kurth J. Dirty, missing instruments plague DMC surgeries. The Detroit News, Aug. 26, 2016. Accessed at http://detne.ws/2bIjohG.
- Kurth J. Lawyers: No recourse for DMC dirty instrument patients. The Detroit News, Sept. 12, 2016. Accessed at http://detne.ws/2c9qjRT.
- Kurth J. Union boss: Cost cuts to blame for dirty DMC tools. The Detroit News, Sept. 13, 2016. Accessed at http://detne.ws/2ckERvo.
- Kurth J. DMC dirty instruments escaped ‘15 probe, records show. The Detroit News, Sept. 21, 2016. Accessed at http://detne.ws/2cxC2az.
