Advertisement

Developing a broader approach to management of infection control breaches in health care settings

      Our experiences with health departments and health care facilities suggest that questions surrounding instrument reprocessing errors and other infection control breaches are becoming increasingly common. We describe an approach to management of these incidents that focuses on risk of bloodborne pathogen transmission and the role of public health and other stakeholders to inform patient notification and testing decisions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rutala W.A.
        • Weber D.J.
        How to assess risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines.
        Infect Control Hosp Epidemiol. 2007; 28: 146-155
      1. Kent County Health Department. Health Alert: Potential exposure to blood borne pathogens in a patient population. November 14, 2007. Available at: http://www.accesskent.com/Health/HealthDepartment/CD_Epid/pdfs/Stokes_Health_Alert.pdf. Accessed September 24, 2008.

      2. New York State Department of Health, Statement by Health Commissioner Richard F. Daines, MD, December 14, 2007. Available at: http://www.health.state.ny.us/press/releases/2007/2007-12-4_finkelstein_statement.htm. Accessed December 15, 2007.

        • Lessa F.
        • Tak S.
        • DeVader S.R.
        • Goswami R.
        • Anderson M.
        • Williams I.
        • et al.
        Risk of infections associated with improperly reprocessed transrectal ultrasound-guided prostate biopsy equipment.
        Infect Control Hosp Epidemiol. 2008; 29: 289-293
        • Gallagher T.H.
        • Studdert D.
        • Levinson W.
        Disclosing harmful medical errors to patients.
        N Engl J Med. 2007; 356: 2713-2719
        • Nelson D.B.
        Infectious disease complications of GI endoscopy: part II, exogenous infections.
        Gastrointest Endosc. 2003; 57: 695-711
        • Weber D.J.
        • Rutala W.A.
        Lessons from outbreaks associated with bronchoscopy.
        Infect Control Hosp Epidemiol. 2001; 22: 403-408
        • Alter M.J.
        Healthcare should not be a vehicle for transmission of hepatitis C virus.
        J Hepatol. 2008; 48 (Epub 2007 Nov 8): 2-4
        • Williams I.T.
        • Perz J.F.
        • Bell B.P.
        Viral hepatitis transmission in ambulatory health care settings.
        Clin Infect Dis. 2004; 38: 1592-1598
        • Bronowicki J.P.
        • Venard V.
        • Botte C.
        • Monhoven N.
        • Gastin I.
        • Chone L.
        • et al.
        Patient-to-patient transmission of hepatitis C virus during colonscopy.
        N Engl J Med. 1997; 337: 237-240
        • Le Pogam S.
        • Bacq Y.
        Nosocomial transmission of hepatitis C virus.
        Ann Int Med. 1999; 131: 794
        • Muscarella L.F.
        The risk of disease transmission associated with inadequate disinfection of gastrointestinal endoscopes.
        J Hosp Infect. 2006; 63: 345-347
        • Spach D.H.
        • Silverstein F.E.
        • Stamm W.E.
        Transmission of infection by gastrointestinal endoscopy and broncoscopy.
        Ann Intern Med. 1993; 118: 117-128
        • Vanhems P.
        • Gayet-Ageron A.
        • Ponchon T.
        • Bernet C.
        • Chayvialle J.
        • Chermorin C.
        • et al.
        Follow-up and management of patients exposed to a flawed automated endoscope washer-disinfector in a digestive diseases unit.
        Infect Control Hosp Epidemiol. 2006; 27: 89-92
      3. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, June 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Accessed November 5, 2007.

        • Centers for Disease Control and Prevention
        A comprehensive strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). Part II: Immunization of adults.
        MMWR Morb Mortal Wkly Rep. 2006; 55: 1-33
        • Centers for Disease Control and Prevention
        Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States.
        MMWR Morb Mortal Wkly Rep. 2005; 54: 1-21
        • CDC
        Guidelines for laboratory testing and results reporting of antibody to hepatitis C virus.
        MMWR Morb Mortal Wkly Rep. 2003; 52: 1-16