updated 6/13/2005 10:48:49 AM ET 2005-06-13T14:48:49

3,800 patients at two hospitals run by Duke University Health System were operated on last year with instruments that were washed in hydraulic fluid instead of detergent, hospital regulators said.

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Duke Health Raleigh and Durham Regional hospitals put patients in “immediate jeopardy” in November and December by not detecting the problem, despite complaints from medical staff about slick tools, according to a report by the Centers for Medicare & Medicaid Services.

The hospitals did not fix the problem for weeks, said the agency, which oversees patient care at hospitals that receive payments from federal insurance programs.

The mix-up apparently occurred when an elevator company drained hydraulic fluid into empty detergent barrels last summer. The detergent supplier later picked up the barrels and mistakenly redistributed them as washing fluid.

Duke Health officials assured patients in January that the likelihood of infection from the tools was “no more than the risk normally associated” with the procedures that the patients underwent.

However, dozens of patients who were exposed to the surgical instruments have reported lingering health concerns ranging from fatigue and joint pain to problems requiring hospitalization, the The (Raleigh) News & Observer reported Sunday.

At least 50 patients who developed complications have taken their concerns to lawyers, though no one has sued Duke or the hospitals. Two lawsuits have been filed against the elevator company and the detergent supplier.

Duke Health officials declined to comment further, citing possible lawsuits.

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