A six-month Detroit News investigation revealed that five Detroit Medical Center hospitals were plagued with dirty, broken and missing surgical instruments for at least 11 years. Our report was based on 200 pages of emails and documents, photographs of dirty instruments, and dozens of interviews with surgeons, former administrators and unionized workers. Instrument problems complicated procedures from cleft palate repairs and spinal fusions, to infant heart repairs and brain surgeries. Patients were kept under anesthesia for an hour or longer while medical staff searched for replacement instruments; dozens of surgeries were cancelled, sometimes after the patients were already anesthetized. Our findings were presented in the context of a growing national problem as hospitals everywhere struggle to keep up with an increase in the number and complexity of surgical instruments. We talked about outbreaks in other cities that were caused by dirty surgical instruments, and provided background on the sterile process and how instruments can harbor pathogens. We also focused on the regulatory gaps and lack of hospital transparency that allowed problems at the DMC to go undetected for more than a decade.
The News’ investigation spurred investigations by the Michigan Department of Licensing and Regulatory Affairs (LARA) and the federal Centers for Medicare and Medicaid Services (CMS). State inspectors cited the DMC for eight health code violations and ordered it to hire a consultant to monitor its sterile processing operations and provide regular reports to the state. Federal inspectors documented practices such as workers putting dirty gloves back in a box with clean ones, and mopping blood from floors without moving equipment, and began the process to sever federal funding if problems weren’t fixed by Dec. 14.
CMS closed its investigation after the DMC passed unannounced inspections in November. Under the oversite of a third-party monitor, the DMC implemented a variety of fixes, and the state closed its investigation after the health system passed on unannounced inspection in December. The Detroit News has published more than 20 follow-up articles documenting the state and federal investigations and providing information on continuing safety concerns at the DMC.