Biohazard: Surgeries Performed with Soiled Instruments

For John Harrison, the surgery he underwent in order to repair his rotary cuff on his right shoulder was anything but routine. It was 2009, and Harrison was 63.  The complications were not immediate, but in the weeks that followed the surgery Harrison became worried about the condition of his new scar. Hot to the touch and beaming in bright red color, the scar began excreting what was referred to as a substance that resembled “butter squeezed from a bag.”

After being advised by the staff of Methodist Hospital of Houston, Texas, to return to the hospital immediately, Harrison and his wife headed back to the hospital where he underwent the initial surgery.  His shoulder, it turned out, had become severely infected with parts of his shoulder bone eaten away, and the metal devices implanted during the surgery had been pulled loose.  And it did not end there–today, Harrison still has trouble doing simple tasks like raising his arm and getting dressed.

Harrison was not alone either, but rather among several other patients who experienced similar post-surgery complications from the same hospital.  Based on this outbreak, the Methodist Hospital was forced to call off knee and shoulder surgeries and close down operating rooms when the Centers for Disease Control and Prevention (CDC) intervened in order to launch an investigation.  Through their efforts, the agency was able to trace the problem to arthroscopic shavers used in surgeries like that which Harrison had went through. 

On closer inspection of the device, it was discovered that remnants of bone, blood, and flesh had not been properly washed away in the sterilizing process and was directly responsible for Harrison’s and the other’s ailments.  While Harrison pursues a lawsuit against Stryker, the manufacturer of the device (for providing inadequate cleansing instructions to hospital employees), this issue is hardly confined to this one hospital.  Instead, the problem of dirty surgical instruments extends much further across the country; and is now shedding a light on gaps in training processes at hospitals nationwide.  The issue may stem from the pressure to deliver clean tools to the operating room quickly; or the fact that the low wage position has a high turn-over rate.  Inefficient cleaning instructions may be yet another concern. 

Mary Olivera, former president of the New York State Association of Central Service Professionals  and current director of sterilization at a New York City medical facility, believes it comes down to job preparedness.  When it comes to those tasked with cleaning up medical equipment and leaving them ready for future use, there is no defined training. “The people who do your nails, they have to take an infection control course before they can apply for a license,” explains Olivera.  “Same with a dog groomer.  Yet the people who deal with lifesaving equipment, they are required to have zero education.”

In order to ensure that all aspects of a surgery and its recovery process are safe, devices used during the procedure need to be safe and clean from the very start.  Workers must complete specific job training that would qualify them to handle and sterilize medical devices before each and every procedure.  For more information, and a chance to put the pressure on government health officials to administer this change, sign the petition here.

Photo Credit: defense.gov/photos/newsphoto.aspx?newsphotoid=6415

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