Some may remember news reports last January regarding dirty duodenoscopes used at various hospitals around the United States, including at Seattle’s own Virginia Mason. If not, links to these stories can be found here:
[‘Superbug’ infected spouse at Virginia Mason, widow told over a year later](http://www.seattletimes.com/seattle-news/health/superbug-infected-spouse-at-virginia-mason-widow-told-over-a-year-later/)
In short, duodenoscopes manufactured by Olympus were defectively designed because they could not be sterilized between uses. As a result, 250 patients developed antibiotic-resistant infections that ended up killing at least 14 patients.
A recent U.S. Senate investigation by Senator Patty Murray’s office into the dirty duodenoscopes scandal confirmed that the manufacturer, Olympus, was responsible for the lion’s share of the blame. Olympus was aware of reports that sterilization of its scopes was difficult and that it was prone to harboring bacteria, but it failed to advise the FDA and U.S, hospitals these issues. Worse, the report notes that Olympus did issue alerts to European hospitals, but failed to provide those same warnings to the FDA or US hospitals.
However, the report also includes some very disturbing information about the conduct of U.S. hospitals. The report notes that several U.S. hospitals traced infections directly to the duodenoscopes, but none of these hospitals shared this information with Olympus or the FDA. The report states:
“Reporting by the hospitals as a whole suggests that rather than collaborate to quickly alert regulators to a potential device problem, hospitals were reluctant to share unconfirmed information. Hospitals as a whole appear to have believed they had an obligation to report only what they could demonstrate beyond any doubt. Such narrow reasoning reveals a misunderstanding about hospital reporting requirements, which are triggered by information that reasonably suggests a device may have caused or contributed to a death or serious injury.”
The entire report can be found here:
[Preventable Tragedies: Superbugs and How Ineffective Monitoring of Medical Device Safety Fails Patients](http://www.help.senate.gov/imo/media/doc/Duodenoscope%20Investigation%20FINAL%20Report.pdf)
The results of this investigation indicate that many hospital administrators are more concerned about keeping and maintaining secrecy when these types of events occur, rather than resolving the problem and ensuring patient safety. This “culture of secrecy” is part of what makes prosecuting medical malpractice cases so difficult. However, instead of reducing liability, hospitals’ “culture of secrecy” is also leads to larger verdicts. This is because when the public finds out that hospitals are more interested in profit and self-preservation, than they are in the health and welfare of its patients, jurors are motivated to award more compensation. Most people can forgive a mistake, whereas a gross breach of trust is much more difficult to overlook.
