State launches probe of dirty DMC instruments
- The News investigated years of complaints about dirty, broken and missing surgical instruments.
- More than 200 pages of emails and internal reports showed doctors’ concerns about patient safety.
- The state Bureau of Community Health Systems announces an investigation of the DMC facilities.
- Advocates are calling for increased transparency in health care for patients.
The state of Michigan launched an investigation into the Detroit Medical Center on Thursday, the same day The Detroit News uncovered years of doctor complaints about dirty, broken and missing surgical instruments.
“Based on The Detroit News story, our bureau has initiated an investigation into issues related to the sterilization of surgical equipment at DMC facilities,” Larry Horvath, director of the Michigan Bureau of Community Health Systems, said in a statement.
“We encourage anyone with a complaint regarding these issues to please contact the bureau.”
The investigation was announced on a day the DMC made no public reaction to The Detroit News stories, but did send a memo to physicians about the stories. Meanwhile, activists pushed for more transparency in reporting on health care issues.
Jason Moon, a spokesman for the Community Health Systems bureau, would not divulge details about the scope and nature of the investigation. The bureau, which covers 20 types of health care facilities, performs state licensing and federal certification regulatory duties as required by state and federal laws. Its activities include issuance of state licenses and construction permits, routine inspections, complaint investigations, enforcement of state and federal requirements, and a host of other regulatory activities.
Complaints can be filed online at michigan.gov/lara or by phone at 800-882-6006.
The bureau’s announcement came hours after The News published an investigation based on more than 200 pages of emails and internal reports showing that doctors have expressed concern about patient safety for at least 11 years because of dirty instruments at the DMC’s campus in Midtown Detroit. The News found that improperly sterilized tools complicated operations from brain surgeries to spinal fusions, kept patients under anesthesia unnecessarily and canceled dozens of operations.
Old blood and bone, even when they go through the sterilization process, are biohazards that can trigger infection and even death if they come into contact with patients.
And although internal complaints may be possible, the likelihood that patients or their families would know that a dirty or broken instrument was involved in their surgeries is low. There’s no requirement that a hospital or its employees reveal that dirty or broken instruments were involved in a surgery.
Detroit Medical Center officials and their for-profit owner, Tenet Healthcare of Dallas, declined requests for comment Thursday about The News’ findings, pointing to an earlier statement saying the system has outsourced management of instrument sterilization to a private company.
But DMC CEO Joe Mullany on Thursday sent a memo to physicians at the hospitals containing “talking points” for employees and patients.
“The DMC disagrees with many assertions made in the article,” the memo said. “Importantly ... there have been no safety issues and/or known Surgical Site Infection (SSI) related to our past CSP services.”
Dirty, missing instruments plague DMC surgeries
The memo adds: “In the spirit of continuous improvement, we chose Unity HealthTrust to help manage our CSP department, which began on June 1. ... We are excited that Unity brings unique strategic solutions for achieving optimal performance within this department.”
The memo urged the doctors to “apologize for any concern this article may have caused” and to assure the patients that “patient safety is always our top priority.”
The News’ story prompted calls for increased transparency in health care that advocates such as Bret Jackson say is lacking.
“Patients should be told what’s gone wrong, and the public has a right to know as well,” said Jackson, president of Economic Alliance for Michigan, a nonprofit that works to lower health care costs. “We need more transparency, more information going to the public about adverse events.”
Detroit Mayor Mike Duggan, who served as CEO of the DMC until he resigned in 2012 to campaign for mayor, also declined comment Thursday on the stories. Duggan attempted to fix the instrument situation in 2010 by consolidating three sterile processing departments serving the systems’ five Midtown hospitals into one in the basement at Detroit Receiving Hospital. The facility serves DMC’s Children’s Hospital of Michigan and the Detroit Receiving, Harper University, Hutzel Women’s and DMC Heart hospitals.
Emails obtained by The News show complaints about missing and dirty surgical instruments continued for years after the consolidation.
“The mayor has been gone from DMC for four years and doesn’t have anything to share,” said John Roach, a spokesman for Duggan, told The News.
The DMC has acknowledged problems with dirty instruments but said patients were not harmed.
DMC, managers trade blame over dirty instruments
Twitter: @kbouffardDN, @joeltkurth
To file a complaint
Here are three methods to file a complaint with the state of Michigan:
1. An online form can be found at michigan.gov/lara.
2. The form, BCHS-361, may be submitted by mail, fax or email.
3. The toll-free complaint hotline is 800-882-6006.
What we found
Here are key findings from a Detroit News investigation into complaints about dirty, missing and incomplete surgical instrument sets at the Detroit Medical Center:
■More than 200 pages of internal emails and records show doctors and administrators complained for at least 11 years about the situation. It has lasted so long some doctors have stopped filing complaints.
■Improperly sterilized tools complicated operations from appendectomies and brain surgeries to cleft palate repair and spinal fusions. Children’s Hospital of Michigan alone reported at least 186 complaints over a 17-month period.
■Patients were kept under anesthesia for up to an hour as staffers replaced instruments. Dozens of operations were canceled at the last minute, some after anesthesia was administered. At least twice, a child’s chest or skull was open for surgery when doctors discovered dirty instruments.
■The issues affect the five hospitals of the Detroit Medical Center’s Midtown campus — Children’s Hospital, Detroit Receiving, Harper University, Hutzel Women’s and DMC Heart hospitals.
■The problems are blamed on a 70-worker Central Sterile Processing Department in the basement of Detroit Receiving that serve the Midtown hospitals. Records show the department is beset with labor friction and low morale and managers have complained disciplining employees is difficult.
■The DMC says no patients were infected because of dirty instruments. It has hired a private company, Unity HealthTrust of Birmingham, Alabama, to assume management of sterile processing and recommend changes.