Update on Duke Medical Mistake Case


Eyewitness News 11.com: Duke Awaits Analysis in Instrument Probe:

It's lean healthcare day on the blog, I guess. This is an update to a story reported earlier.

“Bassett received a letter from Duke in January, which said surgical instruments had not been cleaned properly. The instruments were accidentally washed in hydraulic fluid that had been drained from an elevator and poured into a container labeled as detergent.

A federal investigation found that dirty instruments were used for two months, affecting up to 3,800 patients. Medical staff complained several times about the oily instruments.”

Now there's an obvious application of standard work, 5S, and visual controls (with a big dose of training) to help prevent a problem like this from happening again. That's more disturbing is that medical staff noticed the problem. It sounds like management didn't listen and that they are STILL denying the problem (I'm sure the lawyers are telling them that).

Dr. Victor Dzau is the chief executive officer of Duke University Health System. He says the instruments went through other sterilization stages and analysis of those instruments has been completed.

“[The] conclusion is that it is absolutely sterile,” Dzau said.

Ok, Dr. Dzau — would you go in for surgery with instruments that had been “cleaned” in hydraulic fluid??

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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