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Duke (NC) officials analyzing sterilization mix-up

Healthcare Security Weekly, June 20, 2005

Officials from the Duke University Health System (DUHS) say they are still determining whether patients exposed to surgical instruments washed with a mixture of hydraulic fluid and water are at any risk, reports the Associated Press (AP).

But months after surgeons at Duke Health Raleigh Hospital and Durham Regional Hospital noticed the mistake that resulted in 3,800 surgical patients being operated on with the tainted tools, patients are looking for answers.

Several patients have reported lingering health problems since their surgeries, but investigators haven't found any evidence linking them to the mix-up.

"While we understand that some patients have experienced symptoms following their surgeries, everything we know would suggest that no casual connection has been established between any of these patients' outcomes and instruments exposed to the fluid in the presterilization process," Victor Dzau, MD, CEO of the DUHS told the AP.

The problem came about when elevator workers at the hospital accidentally drained the hydraulic fluid into 15-gal soap containers. The fluid, which looks similar to the soap, was then used in a mix to sterilize surgical equipment.

Initially, surgeons said they thought the instruments felt oily, but thought it may have been the lubricant typically applied to keep them from rusting.

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