Over 70 staff members want to suspend all surgeries at Kaiser Zion Medical Center, a San Diego hospital, after strange particles were found on a series of surgical trays. They signed a petition urging management to cancel all procedures until the matter has been resolved, but it’s not clear what is causing the contamination.
“There are black/gray/brown particles of an unknown substance dusting the interiors of our surgical trays, in addition to black greasy smears of a known, but not surgically-approved substance,” Elizabeth Haynes, a surgical technician at Zion, told The San Diego Union-Tribune. She noted that the contaminants were found on the trays but not the surgical instruments themselves.
However, the hospital has so far rejected the call. “Providing safe, quality, and timely care to our patients is our top priority, and we will continue to schedule surgeries at Zion that can be safely performed,” Kaiser said in a statement. “We have confirmed that all measures we are taking to clean, process and transport surgical equipment to our Zion Medical Center for use [are] safe and medically appropriate.”
The company called the matter an “isolated issue” that was likely caused by something in the water.
“We are currently cleaning and flushing the lines of this equipment to remove all residual particulates,” the hospital added. “In the meantime, surgical instruments used at Zion Medical Center are being safely cleaned and processed at our nearby San Diego Medical Center and an outside agency.”
But Haynes said the problem isn’t under control. Last Friday, she and her team went through 23 trays before they could find one that didn’t contain the contaminants. “We opened 18 trays last night in an attempt to perform one procedure,” Haynes told the outlet Tuesday. She believes there is something wrong with the sterilization process.
All surgical equipment at the hospital is first washed before going into an autoclave, a machine that uses pressurized steam for sterilization.
“The fact that a contaminant is ‘safe’ (not a microbe) doesn’t mean that contaminant is implantable,” she added.
The problem first appeared last month when the facility reported problems with its hot water system. However, Zion has a good reputation when it comes to patient safety. It received an “A” grade from Leapfrog, a national nonprofit that scores hospitals based on cleanliness.
Water is essential for patient safety. Similar issues unfolded at a Boston hospital when the ice machines started leaking chlorine into the water supply back in 2018, resulting in the death of three patients. Researchers looking into the matter published their findings in the medical journal Annals of Internal Medicine.
“Our cluster demonstrates the risk for unintended consequences associated with systems designed to improve hospital water,” the researchers wrote. “Hospitals must be particularly attentive to the threat of water-based infections.”