Penn State Health struggled to maintain a usable supply of sterile instruments for the thousands of surgeries it performed at the Milton S. Hershey Medical Center throughout 2025 and into this year, a Spotlight PA investigation found.

Unsterile instruments increase a patient’s risk of infection and death. Internal documents obtained by the newsroom found Penn State Health’s sterilization issues led to harrowing situations.

Persistent, mysterious black specks dotting trays of surgical instruments.

A lengthy, sometimes dayslong backlog for cleaning and sterilizing medical tools.

Operating room staff piecing together sets of sterile implements because usable ones weren’t readily available.

In one case, an emergency brain operation was done with “contaminated” surgical tools, internal records show.

And in January 2025, the hospital performed a heart surgery with what employees later recognized were unsterile tools, according to four people with knowledge of the situation. An internal review of the incident concluded that safety and error prevention was “not hard wired as standard work” in multiple units.

Contamination problems challenge hospitals across the country. Facilities in Colorado, Florida, and Texas have suspended surgeries over such issues in recent years. To date, Penn State Health has not paused procedures on a similar scale at Hershey Medical Center, the health system’s flagship hospital and the location of the sterilization problems. The most recent public data, from March 2025, show the hospital’s surgical site infection rate is near the national standard.

Scott Gilbert, a health system spokesperson, said in an emailed statement that Hershey Medical Center’s quality standards are working as intended: “all surgical instruments undergo rigorous sterilization processes prior to use,” he wrote. “In addition, any tray that does not adhere to our standards for safety is removed from use.” Penn State Health declined to make any officials available for interviews. (Read more from Penn State Health’s statement here.)

Hershey Medical Center’s issues inflamed disagreements between units and provoked fear among employees, according to internal records and people familiar with the situation. One Penn State Health employee with more than five years of experience told Spotlight PA, “When I see this, what’s happening, this is not us. This is not how it used to be when I was hired there.”

In recent months, Spotlight PA contacted more than 50 people connected to Hershey Medical Center’s operating rooms and sterilization department. Many did not respond to the emails, text messages, or phone calls, but seven did. Each of them asked not to be named due to fears of retaliation for speaking about the situation.

Operating room staff told administrators multiple times that they believed Penn State Health was prioritizing profits and patient volume over safety, according to a summary of a meeting late last year. During that gathering, a pregnant employee who expected to undergo a cesarean section this spring said, “I’m scared to death to come to my own place of work to get it done knowing what we do every day.”

One day in January 2025, Hershey operating room staff gathered surgical tools after completing a heart procedure. The employees placed the instruments in a metal cart, which was wheeled to a nearby elevator and taken down to the hospital’s sterilization unit. There, the surgical instruments would be cleaned and sterilized for another procedure. This process repeats itself tens of thousands of times a year at Hershey Medical Center without causing alarm.

And it would’ve that day too, if not for a strip of paper left among the tools.

A sterilization employee spotted the paper, which is called an indicator. Long before a surgery, the roughly inch-wide strip is placed with the clean tools when they are put in the hospital’s sterilization machines. Chemicals alter the indicator’s color when proper conditions are met in the machine, providing a simple visual confirmation to hospital employees that the tools are sterile and therefore safe to use. Yellow is the desired hue.

The employee saw red.

Medical facilities try to safeguard against errors like this by lining up layers of protection, such as strict processes or extra checks. Ideally, a problem that slips through any one layer is caught by another. Taken another way, when a patient is exposed to harm, multiple things have gone wrong.

Penn State Health performed a heart surgery with unclean tools, in part, because employees in the sterilization unit and operating room who handled them either failed to see the red indicator or did not speak up. (The description of the incident is based on information shared by four people with knowledge of the situation.)

After the finding was reported, the hospital conducted a “root cause analysis,” one of the most intensive forms of internal review. Operating room and sterilization employees, along with several managers, were interviewed. The final document identified more than a dozen systemic issues that contributed to the incident, including that operating room employees lacked a standard way of checking whether instruments were sterile prior to their use.

The February 2025 report, which Spotlight PA obtained, described the hospital’s sterilization unit as “congested” and said employees there rarely used Penn State Health’s internal reporting system to flag problems. Additionally, the hospital was not using software to track all surgical instruments.

The report, sent by Michele Szkolnicki, Hershey Medical Center’s senior vice president and chief nursing officer, said that in the hospital’s operating rooms and sterilization unit “SAFETY BEHAVIORS and ERROR PREVENTION skills are not hard wired as standard work.” The document was shared with people interviewed during the root cause analysis process and patient safety leaders such as Lilian Barker, the hospital’s vice president and chief quality officer.

It noted more than 20 changes that needed to be implemented, including an immediate review of all available or stored surgical equipment to confirm sterility. Penn State Health also ended the employment of several members of the team involved in the surgery, four people with knowledge of the situation told Spotlight PA. This was not a recommendation in the report.

Unsterile instruments present a “significant risk of infection” to a patient, said Peter Nichol, an associate professor of surgery at the University of Wisconsin, in an interview with Spotlight PA. In that kind of situation, a hospital would likely inform the patient about what happened and monitor them for infection, he said.

Whether Penn State Health informed and monitored the patient is not mentioned in the root cause analysis. Gilbert, the health system’s spokesperson, said, “We cannot provide information about the care of a specific patient, but we certainly follow the highest standards and regulatory expectations in terms of post-operative surveillance and patient follow-up.” Gilbert declined to answer questions about the internal report, but said Penn State Health implemented all of the recommendations.

Under state law, a health care facility must notify the Pennsylvania Department of Health, as well as the patient or their family, when someone dies while receiving care or is injured to a degree that necessitates additional treatment. In cases where the person could have been injured but was not, the facility must tell the state’s patient safety oversight group, but is not required to disclose it to the patient. State law shields these records from the public.

Throughout last year, a problem vexed health system officials: Black specks kept appearing in trays of surgical tools arriving in Hershey Medical Center operating rooms. Two people with knowledge of the discussions said Szkolnicki and Don McKenna, the hospital’s president, were involved in meetings regarding the issue.