Editorial: State must step up hospital safety

The Detroit News

The abysmal failure to clean surgical utensils and instruments at the Detroit Medical Center has rightly led to state and federal probes of the sterilizing department. But earlier oversight by the state failed to find the glaring problems. State health officials must step up their game.

An ongoing Detroit News’ investigation revealed improperly cleaned instruments have plagued hospital doctors, surgeons and patients at the medical center for more than a decade. That the problem could evade regulators for so long points to serious cracks in the state’s oversight capabilities.

Worse, regulators from the state’s Bureau of Community and Health Systems last year inspected the Central Sterile Processing Department, where instruments for the five Midtown hospitals are cleaned, and failed to find dirty instruments or any indication of the huge ongoing risks to patient health.

The News discovered that even while the state was on-site inspecting in 2015, an entire set of instruments wasn’t delivered for surgery. And earlier that week surgeons at Children’s Hospital of Michigan had reported unclean clamps, scissors and needle holders, missing parts and other problems leading up to a heart surgery.

These mishaps from the hospital are unacceptable. But it’s also unnerving that the regulatory department tasked with ensuring patient health and safety at Michigan hospitals failed to find such blatant ongoing risks to patients.

It did find other problems with the sterilizing process, including an overly humid facility and staffers in the room without protective gear, among other things. Those alone are serious issues that should have warranted further probing.

Larry Horvath, director of the Bureau of Community and Health Systems, said regulators didn’t specifically check instruments because the department received no complaints indicating there was an issue.

“There’s always a limitation on what we can find because of the duration of inspections,” he said.

But if state inspections are truly too short for regulators to adequately assess hospital safety, the department should make changes to ensure its stamp of approval actually means something.

State Sen. Curtis Hertel Jr., D-East Lansing, who serves as minority vice chairman of the Senate Health Policy Committee, blamed the state’s failures on lack of staff.

“When you don’t have the proper number of staff, it’s difficult to do due diligence that’s required,” he said.

That seems a weak excuse. The department conducted an inspection, but missed the obvious.

Additionally, the Department of Licensing and Regulatory Affairs (LARA) is exhibiting no urgency in addressing failures at the hospital. It conducted a brisk two-day investigation following The News’ report, far short of what’s needed to fix a decade-old problem.

And although LARA declared the poor sterilizing poses no immediate risk to ongoing surgeries, The News’ investigation documented cases in which patients’ health — and their lives — were possibly put at risk due to dirty instruments. Any surgeries currently happening at the hospital carry the same risk.

The report LARA issued since the News’ investigation said workers at the DMC aren’t trained properly and the hospital has 60 days to come up with a plan to fix those problems.

Given how widespread the knowledge of unsterilized instruments has been throughout the hospital complex, training issues should have been addressed years ago.

The real problem is bad management and an environment that accepts substandard performance. And a state inspection regime that failed at its job.