Duke opens web site on recent mix-up in surgery

The Duke University Health System in Durham, NC, has responded to patients' efforts to gain more information about how two hospitals mistakenly washed surgical instruments in used hydraulic fluid instead of detergent and failed to notice the mix-up for weeks. Approximately 3,800 patients were exposed to the contaminated instruments during surgery.

The health system has opened a web page with information on the incidents at http://hydraulicfluidfacts.dukehealth.org. Some of the patients involved in the mix-up had complained that Duke was not forthcoming with information about the situation.

The web site includes patient letters sent since the incident was first revealed, as well as scientific reports and other detailed information.

Staff reported tools feeling 'slick'

The 2004 incident came to light when a report from the Centers for Medicare & Medicaid Services (CMS) concluded that it put patients in "immediate jeopardy" and issued its most serious level of citation. The CMS report indicates that operating room doctors and nurses complained often about surgical tools feeling "slick," and sterilization technicians reported having to run extra wash cycles, but hospital administrators still did not fix the problem for weeks.

The CMS report says 3,800 patients at Duke Health Raleigh (formerly Raleigh Community) and Durham Regional hospitals underwent surgery with instruments that not only were not properly cleaned but were repeatedly drenched in used hydraulic fluid left over from an elevator repair.