For more than a decade, doctors at Detroit Medical Center lodged complaints about surgical instruments. Some were dirty or broken, they said. Others were missing altogether. Now both the CMS and the state of Michigan are investigating the claims, which were aired in a newspaper account late last month.
No matter what investigators find at DMC, unclean surgical instruments and other medical devices are nothing new. The reasons include the difficulty of cleaning some tools, the training and labor conditions of employees tasked with cleaning them and a lack of data and transparency that obscures links between infections and dirty medical instruments.
Jahan Azizi, a retired clinical engineer for risk management at the University of Michigan who is an expert on cleaning medical instruments, said few studies have evaluated the scope of the problem. “If you do not know something exists, you cannot fix it,” Azizi said.
The alleged lapses at DMC, a division of Dallas-based Tenet Healthcare Corp., surfaced only after the Detroit News obtained and reviewed 200 pages of emails and documents. After the story broke, CEO Joseph Mullany wrote in an internal memo that the organization was not aware of any surgical-site infections related to its central sterile-processing services.
Dr. Kenneth Kizer, a professor at the University of California at Davis School of Medicine and former CEO of the National Quality Forum, said it can be hard to pin down the source of an infection acquired during an invasive procedure. And because the role of contaminated instruments is “underappreciated,” he said, they're not the first place people look.