Local News

State investigating mistakes at Cape Fear hospital

Posted October 16, 2008
Updated October 21, 2008

— A division of the North Carolina Department of Health and Human Services will investigate after about 160 patients at Cape Fear Valley Medical Center may have been exposed to staph infection from improperly sterilized surgical instruments.

A hospital technician noticed on Monday that the surgical instruments had not been sterilized with steam.

The affected patients were quickly notified, and no infections have been reported. Officials said the chances of a related infection are low.

"We're conducting a root cause analysis right now to determine exactly what happened," said Clinton Weaver, a hopsital spokesman.

"We need to go through that process and see if it was a process issue or a human error issue."

The hospital says the instruments were cleaned, disinfected and packaged but hadn't been sterilized with steam before they were used on patients last weekend.

Chief medical officer Dr. Eugene Wright said the instruments were believed free of blood-borne diseases like HIV and hepatitis B and C.

He also noted that surgical patients are routinely given antibiotics to ward off infection.

Dr. Chuck Chima, physician adviser to infection control at the hospital, said steam sterilization is the third step of the disinfection process and without it, instruments could be contaminated with bacteria from the hands of employees.

"Most of the (cleaning) process had gone through," Chima said. "The (steam sterilization) is sort of an insurance."

Symptoms of staph infection include redness, swelling, pain and warmth at the surgical site as well as fever and drainage from the surgical area, swollen glands and a red streak from the infection site.

Chima said bacteria could cause regular staph infections, but not Methicillin-Resistant Staphylococcus Aureus, or MRSA, a potentially fatal infection.

Wright said the hospital discovered the problem Oct. 6 when a technician noticed that an instrument package hadn't been steamed. Packages have chemical indicators that show whether they have been exposed to steam.

Officials are investigating the problem, Wright said.

The hospital also has added steps to the sterilization process to make sure all instruments are steamed, he said.

14 Comments

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  • See Chart Oct 16, 2008

    Sure beats elevator fluid oh that was Duke.

  • KingDad Oct 16, 2008

    There are at least TWO direct failures here. The sterile reprocessing department AND the OR.

    Like jkca said below, the indicators are not hard to read. It’s usually tape that resembles old freezer tape. “Plain white tape = no sterilization and brown striped tape = sterilized.” Anybody can learn that. It really bothers me that the OR techs missed it so many times over two days. Not only do they open the instrument sets, count the number of pieces, and set them out on a back table or at the working field, they typically have to physically BREAK that piece of tape to open the instrument set.

    I’m sure this sort of miss happens more than just infrequently. What’s unnerving is the number of mises before it was caught.

  • Air Biscuit Oct 16, 2008

    Although this is unacceptable, make sure that you don't break out the hammer and nails to crucify those responsible. CFV Hospital sees thousands of patients, and in a medical facility of its magnitude, there is still the human element...people are human, and stupid things happen.

    It would be nice if everyone had a career in news reporting...it's the only job field where all employees are as clean as God's fingers.

    wait a minute....what's that sound...(SFX: "Jaws" theme)...I hear the sharks gathering around for a feeding frenzy...fins to the left, fins to the right....shark attack! It's LAWYER time!

  • Qwerty27807 Oct 16, 2008

    So... Now what? Give the patients a coupon for "Buy one, get one free endoscopy"? Maybe send them a "customer satisfaction" survey and make a Powerpoint presentation of the results?

    I work in a hospital, and I can guarantee you that events like this are NOT at all rare, what is unusual in this case is that it was publicly reported. (Hear that barking? Thats the pack of lawyers running to Fayetteville to seek clients.)

  • Rolling Along Oct 16, 2008

    Welcome to a world driven by profit margins and little else.

  • Adelinthe Oct 16, 2008

    "Wright said the instruments were believed free of blood-borne diseases like HIV and hepatitis B and C."

    Oh now, don't we feel better because he "believed" the instruments are free of the listed diseases.

    Wonder if his beliefs will keep those affected free of them.

    What a bunch of idiots. Who wasn't doing their job properly??? And do they still work there???

    Cause this isn't a case of forgetting to put a filter in the coffee maker for heaven's sakes.

    God bless.

    Rev. RB

  • Justabum Oct 16, 2008

    I have been a patient in this hospital on two separate occasions and have no complaints about the care.

  • bbad238 Oct 16, 2008

    That's absolutely rediculous and someone should be fired! They need a review, right down to their hiring practices because someone isn't doing the job. I wouldn't go to that hospital unless it was a dire emergency!

  • WHEEL Oct 16, 2008

    Take your choise, no steaming or cleaning with used hydraulic fluid or maybe an organ transplant of the wrong blood type. Sure inspires great confidence in the medical establishment of N.C.

  • this is my Screen Name Oct 16, 2008

    Bet there are some extra barrels of elevator lubricant sitting around somewhere that they could get cheap.

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