Safety culture credited with catching tool-cleaning error
Patient Safety Monitor Alert, July 12, 2005
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Wake Forest University Baptist Medical Center in Winston-Salem, NC, discovered that some surgical tools were inadvertently washed in hydraulic fluid. Unlike a similar problem at Duke University Health Systems, however, the Wake Forest team discovered the problem right away and washed out both their cleaning equipment and the tolls before anything was used on a patient, according to the Durham-based Herald-Sun.
Wake officials credited a culture of safety in their facility for catching the problem before any patients were exposed. Low-level technicians noticed that the tools felt greasy coming out of the cleaning process and immediately stopped the process. When they checked the bucket of cleanser, it seemed darker than normal and dirty. Other buckets looked the same, and it was later discovered that the material was actually hydraulic fluid.
The center has a near-spotless complaint record for hospital cleanliness and conditions.
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