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It's unsettling to learn that a life-saving surgery can compromised by a tech who didn't spend a few extra minutes cleaning the tools properly. I had read that

It's unsettling to learn that a life-saving surgery can compromised by a tech who didn't spend a few extra minutes cleaning the tools properly. I had read that surgeons were moving into using disposable instruments because of the possibility of prion contamination (prions can't be destroyed by an autoclave). But maybe that was only for neurosurgery?

chongli 7y ago
For such life-and-death critical jobs involving routine and mundane steps, we would be wise to employ a memory aid system. One good example is the way Japanese rail-workers wear white gloves and point at things [1] as they complete their routine checks. [1] https://www.atlasobscura.com/articles/pointing-and-calling-japan-trains https://www.atlasobscura.com/articles/pointing-and-calling-j...
DoctorOetker 7y ago
I also remember since a long time knowing that the surgical tools themselves were disposable (the price for a little bit of steel is nothing compared to the value of the operation for example), perhaps they mean the tool holders or more complicated instruments that hold the tools?
- deleted 7y ago
  [deleted]
- rscho 7y ago
  Most surgical instruments are absolutely not disposable. I don't think you can realistically represent yourself how much increase in healthcare costs that would imply. We are talking billions.
throwaway911411 7y ago
For neurosurgery, when operating on a patient with suspected prion disease, the surgery will be done with disposable instruments as much as possible. This may mean however that the surgeon will have to use a hand drill, instead of a power drill. For the other cases without prions, normal sterilization works. And you don’t want to throw away all your equipment after each surgery. A neurosurgical power drill can cost around $20,000 - $40,000
- Mtinie 7y ago
  Presumably picked up by someone’s insurance plan, or a “not my problem” situation for the attending surgeon. Sub-sanitized instruments should not be a possibility given our current understanding of infections and their root causes. In my case, I’d rather have one less test to confirm something, if it means I get to have my surgical implements experience one more run through the UV sterilizer or the autoclave before they are used on me. Better yet, why not use a whole new set of virgin tools following a time-proven blueprint?
- pnutjam 7y ago
  They don't have to be designed with motors and such accessible to contamination.
Reason077 7y ago
I had surgery to remove impacted wisdom teeth around 10 years ago. I recall the surgeon telling me at the time that he used new instruments every time because of the risk of prion diseases.
jdietrich 7y ago
> It's unsettling to learn that a life-saving surgery can compromised by a tech who didn't spend a few extra minutes cleaning the tools properly. Why are the devices so difficult to clean? Why are processes in sterile processing units so chaotic? Why aren't decontamination errors being picked up by quality control? It's never the fault of the guy on $8.50 an hour. The buck stops with management; the buck always stops with management.
- b_tterc_p 7y ago
  > It's never the fault of the guy on $8.50 an hour. The buck stops with management; the buck always stops with management. Not really. Persistent problems are management’s fault. Individual errors are made by individuals.
  - 0xcde4c3db 7y ago
    Even with an individual error, the system/office/company put the individual in the position to make the mistake, and then didn't provide adequate accommodation or procedure to prevent the mistake. Not every individual mistake can reasonably be averted with changes to the system, but it's vitally important that we at least ask the question of how the system failed. Otherwise we're virtually guaranteed to wind up with a pile of "unrelated incidents" that might have been prevented at little to no cost.
  - jdietrich 7y ago
    There's no such thing as an "individual error" - every individual is operating within a management structure. Every error has the chance to be prevented before the fact or mitigated after the fact by proper quality management. Even if that individual is a lazy idiot who shouldn't be trusted with pointy scissors, whose fault is it for hiring him? All errors exist on a spectrum of foreseeability and severity. Is it foreseeable that someone might miss a spot when cleaning? Yes, clearly, even if they're exceptionally diligent and well trained. The odds of them making that error diminish with training, skill and care, but they never reach zero. How severe are the likely consequences of that error? In this case, someone could die of sepsis. You can't just shrug and say "the guy who was supposed to clean the device didn't do it properly, it's not our fault". Why did that error happen? What could management have done to reduce the probability of that error? How could that error have been detected before a patient was put at risk? From reading the story, I think it's abundantly clear that many opportunities to reduce risk are being missed due to poor management of the process.
TazeTSchnitzel 7y ago
Don't blame the techs when device manufacturers make theirs too complicated to reasonably clean and provide unclear instructions, and when their management pay them barely above minimum wage and pressure them to work as quickly as possible.

chongli 7y ago

For such life-and-death critical jobs involving routine and mundane steps, we would be wise to employ a memory aid system. One good example is the way Japanese rail-workers wear white gloves and point at things [1] as they complete their routine checks. [1] https://www.atlasobscura.com/articles/pointing-and-calling-japan-trains https://www.atlasobscura.com/articles/pointing-and-calling-j...

DoctorOetker 7y ago

I also remember since a long time knowing that the surgical tools themselves were disposable (the price for a little bit of steel is nothing compared to the value of the operation for example), perhaps they mean the tool holders or more complicated instruments that hold the tools?

deleted 7y ago
[deleted]
rscho 7y ago
Most surgical instruments are absolutely not disposable. I don't think you can realistically represent yourself how much increase in healthcare costs that would imply. We are talking billions.

throwaway911411 7y ago

For neurosurgery, when operating on a patient with suspected prion disease, the surgery will be done with disposable instruments as much as possible. This may mean however that the surgeon will have to use a hand drill, instead of a power drill. For the other cases without prions, normal sterilization works. And you don’t want to throw away all your equipment after each surgery. A neurosurgical power drill can cost around $20,000 - $40,000

Mtinie 7y ago
Presumably picked up by someone’s insurance plan, or a “not my problem” situation for the attending surgeon. Sub-sanitized instruments should not be a possibility given our current understanding of infections and their root causes. In my case, I’d rather have one less test to confirm something, if it means I get to have my surgical implements experience one more run through the UV sterilizer or the autoclave before they are used on me. Better yet, why not use a whole new set of virgin tools following a time-proven blueprint?
pnutjam 7y ago
They don't have to be designed with motors and such accessible to contamination.

Reason077 7y ago

I had surgery to remove impacted wisdom teeth around 10 years ago. I recall the surgeon telling me at the time that he used new instruments every time because of the risk of prion diseases.

jdietrich 7y ago

> It's unsettling to learn that a life-saving surgery can compromised by a tech who didn't spend a few extra minutes cleaning the tools properly. Why are the devices so difficult to clean? Why are processes in sterile processing units so chaotic? Why aren't decontamination errors being picked up by quality control? It's never the fault of the guy on $8.50 an hour. The buck stops with management; the buck always stops with management.

b_tterc_p 7y ago
> It's never the fault of the guy on $8.50 an hour. The buck stops with management; the buck always stops with management. Not really. Persistent problems are management’s fault. Individual errors are made by individuals.
- 0xcde4c3db 7y ago
  Even with an individual error, the system/office/company put the individual in the position to make the mistake, and then didn't provide adequate accommodation or procedure to prevent the mistake. Not every individual mistake can reasonably be averted with changes to the system, but it's vitally important that we at least ask the question of how the system failed. Otherwise we're virtually guaranteed to wind up with a pile of "unrelated incidents" that might have been prevented at little to no cost.
- jdietrich 7y ago
  There's no such thing as an "individual error" - every individual is operating within a management structure. Every error has the chance to be prevented before the fact or mitigated after the fact by proper quality management. Even if that individual is a lazy idiot who shouldn't be trusted with pointy scissors, whose fault is it for hiring him? All errors exist on a spectrum of foreseeability and severity. Is it foreseeable that someone might miss a spot when cleaning? Yes, clearly, even if they're exceptionally diligent and well trained. The odds of them making that error diminish with training, skill and care, but they never reach zero. How severe are the likely consequences of that error? In this case, someone could die of sepsis. You can't just shrug and say "the guy who was supposed to clean the device didn't do it properly, it's not our fault". Why did that error happen? What could management have done to reduce the probability of that error? How could that error have been detected before a patient was put at risk? From reading the story, I think it's abundantly clear that many opportunities to reduce risk are being missed due to poor management of the process.

TazeTSchnitzel 7y ago

Don't blame the techs when device manufacturers make theirs too complicated to reasonably clean and provide unclear instructions, and when their management pay them barely above minimum wage and pressure them to work as quickly as possible.