Hershey, Pa.-based Penn State Health’s Milton S. Hershey Medical Center said it has addressed sterilization unit issues after a January 2025 incident, but employees are still raising concerns, according to a May 14 report from Spotlight PA.
Seven unnamed individuals connected with Hershey Medical Center spoke to Spotlight PA for the report, which a Penn State Health spokesperson called “inaccurate and wildly sensational” in a statement to Becker’s.
Here are five things to know from the report:
- “Four people with knowledge of the situation” told Spotlight PA that unsterile tools were used during a heart surgery in January 2025.
According to Spotlight PA, sterilization unit and operating room employees who handled the unsterile tools before the surgery either failed to see a red sterile instrument indicator on the instrument tray or saw the indicator and did not speak up. - After the incident was reported, the hospital launched an investigation and found “more than a dozen systemic issues” contributed to the incident and identified “more than 20 changes” necessary to address the issue.
An investigation report viewed by Spotlight PA categorized the hospital’s sterilization unit as “congested,” and found staff were not consistently using internal reporting systems or software to track surgical instruments or flag issues.
The investigation report also said “safety behaviors and error prevention skills are not hard wired as standard work.” - A Penn State Health spokesperson told Spotlight PA that the health system has implemented all of the report’s recommendations.
Several team members involved in the surgery are no longer employed at the hospital, the Spotlight PA report said.
- In addition to the January 2025 incident, employees have said “black specks” continued to appear on surgical instrument trays.
“The prevalence of the black specks — along with what two people described as an understaffed sterile processing unit — contributed to a shortage of available surgical instruments,” the Spotlight PA report said.
“The existence of plastic particulate specks on some surgical instruments and in some instrument trays after sterilization is a common challenge in hospitals across the country and around the world,” the Penn State Health statement said. “To date, this issue has affected a minute fraction of the instrument trays we sterilize.”
The system told Spotlight PA that only 24 out of 15,300 surgeries were postponed due to instruments “not meeting the health system’s standards.”
Four experts with no connection to Penn State Health said “the hospital’s problem with black specks is not uncommon across the country,” according to the Spotlight PA report.
- “Today’s Spotlight PA story about the Milton S. Hershey Medical Center provides an inaccurate and wildly sensational description of our processes and procedures, conflating different issues and unnecessarily raising concerns among patients needing surgical procedures,” the Penn State Health statement said.
“Our closely monitored patient safety metrics and indicators have remained stable. Those metrics put us among the best healthcare institutions in the country. Our regulators at the state and federal levels have approved our efforts to manage the occasional identification of particulate specks.
“As we continue to take comprehensive steps toward a solution, patient safety remains the only consideration involved in every decision we make.”
Read the full Spotlight PA report here.
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