Investigation Reveals Problems With Dirty Medical Tools at DMC Hospitals
When you check into the hospital for surgery or any other medical procedure, you check in believing that you will be receiving the highest level of care. You trust that your doctor knows exactly what they’re doing, that the nurses know how to best care for you, and, at the very least, the people taking care of you will be using clean, sterilized tools. However, a recent report by the Detroit News shows that DMC Hospitals in Detroit have been facing an ongoing problem with missing, broken, and inadequately sterilized medical tools.
The Detroit News spent six months investigating the problem and reviewed over 200 pages worth of internal emails and reports indicating these problems have been going on for at least eleven years. DMC hospitals include five different hospitals — Children’s, Detroit Receiving, Harper University, Hutzel Women’s, and DMC Heart — and these problems with medical tools appear to have impacted all five hospitals equally. Between all five hospitals, they perform over 37,000 operations annually.
Many surgeons at DMC hospitals routinely receive incomplete surgical tool kits, tools that are broken, and surgical tools that still have blood or tissue on them from previous procedures. Over the course of 17 months recently, surgeons at Children’s Hospital alone made 186 complaints about dirty or missing surgical tools. Even if an instrument has been sterilized, things like blood and tissue that remain on instruments are still biohazards and can cause things like infections or septic shock if they come into contact with another patient.
Not only do unsanitary medical tools put patients at risk of being exposed to biohazardous materials, they can also prolong medical procedures, placing the patients at a higher risk for complications. When broken, missing, or dirty surgical tools are uncovered during a procedure, the surgical team has to stop working to either replace or fix the tool, forcing the patient to stay under anesthesia for a longer amount of time. In some cases, operations are not completed or have to be cancelled, often at the very last minute after the patient has already arrived at the hospital and been placed under anesthesia. In one email from June 2015, a doctor at Children’s Hospital complained to administrators that they were cancelling up to 10 procedures per week. Another doctor said he’s been forced to cancel 30-40 operations in the past two years because of problems with instruments.
Surgical tool sterilization isn’t handled by the surgeons themselves, it’s handled by a separate team of technicians. The long-standing problems with missing, broken, and improperly sterilized tools have left many DMC surgeons extremely frustrated. They’ve filed complaints over and over about the problem, but they feel like nothing ever gets done to solve the problem. One surgeon told the Detroit News that he’d given up on filing formal complaints about the problem over a year ago, despite the fact that he regularly receives surgical tools with old blood and tissue still on them, because it just feels useless to him. And one sterilization manager told the Detroit News that a lack of support from management and union rules made it virtually impossible to discipline sterilization workers unless the surgeons photographed the problem.
In May 2016, management of DMC’s sterile processing department was taken over by a company based in Birmingham, Alabama, but doctors say they haven’t noticed a change since then. According to internal emails, 95% of all surgical instruments at DMC hospitals were delivered without any problems in June 2014. When the Detroit News did the math, that came out to be 50,000 errors per million instruments. The ECRI Institute in Philadelphia says most sterile processing managers aim for no more than 3.4 errors per million.
Within hours of the Detroit News publishing their investigation, the state of Michigan announced they would be investigating the problems at DMC hospitals.