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        New Message Board Archives >> 2005 General Board Posts >> Duke slow to find fluid error
        
(Message started by: burnt-toast on Jun 15^th, 2005, 7:39am)

Title: Duke slow to find fluid error
Post by burnt-toast on Jun 15^th, 2005, 7:39am

Makes one feel real uncomfortable with the Q/A processes applied before/during/after surgical treatments.

http://www.dukenews.duke.edu/2005/06/clips061305.html

Tom

Title: Re: Duke slow to find fluid error
Post by yikes-another-one on Jun 15^th, 2005, 12:29pm

:o

I just saw the report on GMA this morning.
the hospital says, "Infections rates did not change"
and Diane tried to point out that the fluid would cause
"auto-immune" troubles...not infections..... ::)

Unbelieveable.

the Elevator company will be the scapegoats, for sure.

Now the OR is like outter space for me.
I just don't need to go there....

Title: Re: Duke slow to find fluid error
Post by seasonalboomer on Jun 15^th, 2005, 12:42pm

when you boil this one down I believe you end up having to look at the distance people feel they are from the process. for instance, if I'm running a sanitizer and I'm using a similar looking substance to clean the instruments, but when I run it, it gives off a wierd smell. in the world I work in (I'm lucky), I go to a supervisor and say, "this don't smell right -- I think something's wrong." The supervisor says, "you know I think you're right, lets take it to someone who knows something about this and make sure what we're doing is right."

In this case even O.R. personnel were saying, "this scalpel seems kind of greasy to me." And no one says, "you know, you're right, let's get this checked out."

What kind of system has been created that no one quesitons things. Have we reached the point where we have either a.) been so reinforced that the system can't be broken, or b.) had so many experiences trying to fight a broken system that it "just isn't worth it."??? Just use the fucking instruments and let's get on with it.

Title: Re: Duke slow to find fluid error
Post by burnt-toast on Jun 15^th, 2005, 12:49pm

Unbelieveable

An elevator company drains hydrolic fluid into hospital barrels and leaves them in a corner of a parking lot.

Duke calles the detergent supplier and told them to remove their barrels.

The detergent supplier retrieves the barrels and puts them back into inventory despite broken seals.

Duke orders their supply of detergent and receives the same barrels with broken seals and simply puts them into service.

Surgens and Surgical staff report a strange substance on their instruments that is staining the liners of their surgical trays but continue performing surgeries

Duke blows off their reports, doesn't cancel or delay a single surgery

Finding fault doesn't seem to be a problem.

Duke potentially has a few thousand patients that need some kind of help.

Tom

Title: Re: Duke slow to find fluid error
Post by Lizzie2 on Jun 15^th, 2005, 7:51pm

Wow!! I'm actually pretty surprised that they have that information on DUKE'S website!! LOL Maybe they are trying to make up for the mistake (or take less criticism) by being open about it? Interesting...

Yeahhhhh hospitals and their sterile environments... I dunno sometimes. Although in the OR for the surgeries I observed, they ran a very tight ship. There was no question about who did what...and they'd near bite your head off for coming within a foot of the blue sterile drape. "DON'T TOUCH THAT!!!" LOL

All I can say from past experience is that you should inspect your food trays/silverware/dishes closely! If they look really bad, then request styrofoam. I won't even share the stories from when I worked in dietary nutrition for about 3 years, but I definitely would not have eaten off that hospital's silverware or plates!! haha

This is a pretty wild mistake, though!!

L2 :)