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Third North Carolina Hospital Received Barrels of Hydraulic Fluid

Jun 22, 2005 | AP

A third North Carolina hospital said Wednesday that it received barrels that were supposed to contain a cleanser for surgical instruments but instead contained hydraulic fluid.

A spokesman for Wake Forest Baptist Medical Center said hospital workers caught the mistake immediately and no patients underwent surgery with instruments washed in the fluid.

It was not immediately clear if there was a connection between the discovery at the Winston-Salem hospital and similar discoveries at two other hospitals. But all three hospitals used the same soap supplier, Cardinal Health of Dublin, Ohio.

Wake hospital spokesman Mark Wright said that two loads of surgical equipment came out of a washer Dec. 13 feeling greasy. Workers halted the cleaning and checked the barrels, which were supposed to contain cleanser but instead contained hydraulic fluid.

Workers then re-cleaned the surgical equipment several times, and "no contaminated equipment came into contact with patients," Wright said in a statement.

Officials at the Winston-Salem hospital were unaware at the time that any other hospital had received barrels of hydraulic fluid, he said.

For two months late last year, surgeons at Duke Health Raleigh Hospital and Durham Regional Hospital unknowingly used instruments on nearly 4,000 patients that had been washed with hydraulic fluid instead of soap.

Duke University sent letters to patients this week, saying there's no risk of infection from those instruments. The letters did not address patients' fears that the mistake led to an increased risk of autoimmune or other noninfectious disorders.

The error at the Duke hospitals happened after elevator workers drained hydraulic fluid into empty soap containers without changing the labels.

Later, a hospital administrator saw the containers on a pallet and had them moved, believing they were soap. The unneeded soap was returned to the distributor, who shipped it back to the Duke hospitals upon getting a new order.


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