Monday, August 22, 2011

Here's your infected speculum ... yum.

So this is pretty much the most horrifying public health lapse that I've heard of recently in our nation ... and guess what? It happened right here in Texas.

Apparently the Parkland Memorial Hospital incorrectly sterilized not just a few, but at least 70 speculums.
A March 2010 letter to clinic patients said, "We would like to let you know that you may have been exposed to a speculum"—a vaginal examination instrument—"that may not have been properly sterilized." Although the infection risk was very low, the letter added, "we would like to evaluate you in our OB/Gyn Intermediate Care Center as soon as possible to offer you preventive medications."
Two days later, another letter told clinic patients they needed to also alert them to the possibility of infecting a sexual partner. "We would recommend that you abstain from sexual intercourse or use condoms until notified of negative results after your six month follow up," the letter said.
A third letter soon went out to a different group of women that warned of another possible failure to sterilize instruments. This time the problem had occurred in Parkland’s labor and delivery department, one of the nation’s busiest.
Yep, so this information is just now coming to light because of freedom of information inquiries. Can you imagine being one of these women? Getting letters like this out of the blue, telling you that some rotten and unclean speculum has been used during your exam? I just threw up a little bit.

Hospitals are supposed to be bastions of professionalism and cleanliness, and yet we hear about events like this all the time. Infections that kill patients, botched operations, ineffective medication management. Mistakes like these, if made in other industries, wouldn't be such a big deal; the auditor catches the misplaced decimal point, the copy editor corrects the grammar error, the janitor cleans up your spill. But in the medical community, we can't just write off errors such as these to human nature.

We have to wonder, also, whether this hospital possesses the correct financial and administrative resources to serve the needs of its surrounding community. I'm not familiar with the demographics of the nearby region, but the hospital may primarily serve underprivileged individuals; if this is the case, perhaps more government funding is necessary to ensure the availability of equipment and staff to guarantee patient safety.

I think many hospitals lack the financial or managerial resources to institute proper systematic controls that would prevent errors such as these. Why would a system allow technicians to retrieve dirty speculums? Shouldn't there be a mechanical safeguard to stop such an event? Further, what kind of managerial pressures are being exerted on technicians to sterilize quickly without regard to process quality?

In short, the hospital has pledged to fix this problem through increased monitoring, but I don't think that's the problem. An environment that encourages productivity over safety, regardless of the product, is unsafe for everyone. This is true of manufacturing environments, hospitals, and even office workplaces.

I think a careful analysis of the organization's culture will reveal far greater problems than dirty speculums. Perhaps the hospital, under threat of lost Medicaid and Medicare funding, will learn to clean up its act.

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