It may be difficult to imagine, but two North Carolina hospitals performed some 3,800 surgical procedures over the course of November and December 2004 using surgical instruments that had been "washed" in hydraulic fluid drained from the hospitalsÃ elevators into empty soap containers which were never relabeled.
Although doctors and staff complained that some of their surgical instruments felt "slick," Durham Regional Hospital and Duke Health Raleigh Hospital did not unravel this mystery until January when they notified the affected patients about the mix-up.
While Duke assured their patients there was little chance the mistake would cause medical problems, the hospitals may be in for some problems of their own. The federal Centers for Medicare and Medicaid Services has already determined that both hospitals had endangered their patients and North Carolina investigators have cited the hospitals and the elevator company for a number of mistakes.
The hydraulic fluid is considered to be "pretty toxic stuff" according to Dr. Michael Grodin, director of medical ethics at the Boston University School of Medicine. Dr. Grodin was at a loss to explain how hydraulic fluid could be confused with soap since the two liquids are so different. A second "more interesting" question for Dr Grodin centers on the extraordinary length of time it took "to figure it out."
The hospitals claims the instruments were sterilized in a steam bath after they were "washed" in the hydraulic fluid. Both hospitals have taken steps to prevent this type of occurrence in the future.
Some 15 or 20 of the affected patients have contacted a Raleigh attorney with complaints of infections and painful joints. One patient has already sued the elevator company claiming the mistake caused severe infection, temporary loss of kidney function, and other injuries.