Last fall, operating room nurses at Ann Arbor's Veterans Administration hospital began noticing little specks of particulate matter in surgical instrument trays.
The specks meant that surgery had to be rescheduled or canceled, if a speck-free replacement tray was unavailable.
Initially attributed solely to a water main break, months later, some surgeries are still being canceled due to particulate matter on the trays, despite the hospital taking a number of steps.
Eric Young is acting director of the Ann Arbor VA.
"It's complicated for a few reasons," says Young. "It's a subtle problem. The parts are very small, and it's intermittent, so it's hard to tell if something you've done is working. And there are multiple sources, from water, from byproducts of sterilization like the soaker sheets lining the trays."
Young says the situation is getting better, however, and the hospital is abiding by the first rule of medicine, which is "first, do no harm."
"Overall, our cancelation rate is close to the national VA average," says Young. "It would probably be much below average were it not for this particular issue. And we are very sure that no patients have been directly harmed. We track outcomes very carefully at the patient level and through aggregated statistics. Our outcomes are good and there have been no unexpected complications, including infections."
Until the situation is completely resolved – or resolved as much as possible – the VA is sending cardiac surgeries to to the University of Michigan.