Outbreaks and Patient Notifications in Outpatient Settings
The following table includes examples of recent outbreaks and patient notification events occurring in a variety of outpatient settings including primary care clinics, pediatric offices, ambulatory surgical centers, pain remediation clinics, imaging facilities, oncology clinics, and health fairs. This is not an exhaustive list but it serves as a reminder of the serious consequences that can result when healthcare personnel fail to follow the basic principles of infection control. Such consequences include: infection transmission to patients, notification of thousands of patients of possible exposure to bloodborne pathogens, referral of providers to licensing boards for disciplinary action, and malpractice suits filed by patients.
These events are preventable, yet they continue to occur. Facilities and healthcare personnel are urged to review the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care and its accompanying Infection Prevention Checklist to assess the policies and procedures in their facility as well as their own personal practices to assure they are in accordance with evidence-based guidelines and to prevent patient harm.
Setting | Year Investigated |
Pathogen(s) |
Infection(s) |
Patient notification performed
(# notified) |
Infection Control Breaches Reported |
---|---|---|---|---|---|
Urology Clinic [1] | 2011 |
N/A* |
N/A* |
Yes (101) |
1) Single-use needle guides (for prostate biopsy) used for >1 patient |
Pediatric Clinic [2] | 2011 |
N/A* |
N/A* |
Yes (Not reported) |
1) Syringe reuse (i.e., using the same syringe to administer influenza vaccine to >1 patient) |
Pain Remediation Clinic [3] | 2010 |
Hepatitis C Virus |
Hepatitis |
Yes (>2,000) |
1) Syringe reuse (i.e., double dipping)† |
Heath Fair [4] | 2010 |
N/A* |
N/A* |
Yes (50) |
1) Same fingerstick device used on >1 patient to obtain blood samples for blood glucose monitoring |
Outpatient Radiology Facility [5] | 2010 |
Streptococcus salivarius |
Meningitis |
No |
1) Healthcare providers did not wear facemasks when performing spinal injection procedures 2) Contents from single-dose vials used for >1 patient |
Allergy Clinic [6] | 2009 |
Mycobacterium abscessus | Skin and Soft Tissue Infection | No | 1) Inappropriate selection and dilution of skin disinfectant |
Hematology-Oncology Clinic [7] | 2009 |
Hepatitis B virus | Hepatitis | Yes (2,700) | 1) Medication preparation in a blood processing area 2) Contents from single-dose vials and saline bags used for >1 patient |
Outpatient Pain Clinic [8] | 2009 |
Staphylococcus aureus | Bloodstream Infection Meningitis Epidural/Presacral Abscess |
Yes (110) | 1) Syringe reuse (i.e., double dipping)† 2) Contents from single-dose vials used for >1 patient 3) Healthcare providers did not wear facemasks when performing spinal injection procedures |
Primary Care Clinic [9] | 2009 |
Staphylococcus aureus | Joint Infection | No | 1) Mishandling of multi-dose vials used for >1 patient (e.g., handling in the immediate patient treatment area and failure to store according to manufacturer instructions) 2) Inadequate hand hygiene 3) Incorrect cleaning and disinfection of medical equipment |
Cardiology Clinic [10] | 2008 |
Hepatitis C Virus | Hepatitis | Yes (1,205) | 1) Syringe reuse (i.e., double dipping)† |
Pain Remediation Clinic [11] | 2008 |
Klebsiella pneumoniae, Enterobacter aerogenes | Bloodstream Infection | No | 1) Contents from single-dose vials used for >1 patient 2) Lack of hand hygiene before procedures 3) Not appropriately cleaning the injection site prior to injection |
Ambulatory Surgical Center (single-purpose endoscopy center) [12] | 2008 |
Hepatitis C Virus | Hepatitis | Yes (>50,000) | 1) Syringe reuse (i.e., double dipping)† 2) Contents from single-dose vials used for >1 patient |
Obstetrician/ Gynecologist Office [13] | 2007 |
N/A* | N/A* | Yes (36) | 1) Syringe reuse (i.e., using the same syringe to administer influenza vaccine to >1 patient) |
Multiple Gastroenterology Clinics [14] | 2007 |
Hepatitis C Virus, Hepatitis B Virus |
Hepatitis |
Yes (4,490) | 1) Syringe reuse (i.e., double dipping)† 2) Contents from single-dose vials used for >1 patient |
Pediatric Oncology Clinic [15] | 2007 |
Polymicrobial | Bloodstream Infection | No | 1) Contents from single-dose vials used for >1 patient 2) Predrawing saline flush solutions |
Dermatology Office [16] | 2007 |
N/A* | N/A* | Yes (13,500) | 1) Medical equipment (i.e., scalpels, gloves, syringes, and suture material) designed and intended to be used on a single patient used on >1 patient. |
* Infection control breach, not infections, prompted patient notification. It is not known if any infections resulted from the unsafe practices.
† Double Dipping: Syringe that had been used to inject medication into a patient, reused to enter a medication vial. The syringe is discarded but contents from that vial, which were contaminated through reuse of the syringe, are then used for subsequent patients.
References:
- Southern Nevada Health District. Health District distributing patient letters
- CBS Denver. Children told to be tested for HIV after flu vaccines reused
- Los Angeles County Department of Public Health. Information about Hepatitis Investigation
- Indian Health Service. New Mexico Health Fair Participants Urged to Seek Additional Testing. [PDF - 56 KB] Press Release May 20, 2010. [Accessed 3 Mar 2011].
- 60th Annual Epidemic Intelligence Service (EIS) Conference Program Schedule [PDF - 13.12 MB]
- Allergy Injection-Associated Mycobacterium abscessus Outbreak — Texas, 2009 IDSA
- Greeley RD, Semple S, Thompson ND et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. AJIC 2011; Jun 8 [Epub ahead of print].
- Radcliffe R, Meites E, Briscoe J et al. Severe methicillin-susceptible Staphylococcus aureus infections associated with epidural injections at an outpatient pain clinic. AJIC 2011; Jul 20 [Epub ahead of print].
- Methicillin-susceptible Staphylococcus aureus Infections After Intra-Articular Injections at a Primary Care Clinic IDSA
- Moore ZS, Schaefer MK, Hoffmann KK, et al. Transmission of Hepatitis C Virus During Myocardial Perfusion Imaging at an Outpatient Clinic. Am J of Cardiol. 2011;108(1):126-132
- Wong MR, Del Rosso P, Heine L, et al. An outbreak of Klebsiella pneumoniae and Enterobacter aerogenes bacteremia after interventional pain management procedures, New York City, 2008. Reg Anesth Pain Med. Nov 2010;35(6):496-499.
- Fischer GE, Schaefer MK, Labus BJ, et al. Hepatitis C Virus Infections from Unsafe Injection Practices at an Endoscopy Clinic in Las Vegas, Nevada, 2007-2008. CID. Aug 2010;51:267-273.
- Nassau County and State Health Departments Alert 36 Patients to Infection Control Error by Long Island Doctor
- Gutelius B, Perz JF, Parker MM, et al. Multiple Clusters of Hepatitis Virus Infections Associated with Anesthesia for Outpatient Endoscopy Procedures. Gastroenterology 2010;139(1):163-170.
- Wiersma P, Schille S, Keyserling H, et al. Catheter-related Polymicrobial Bloodstream Infections among Pediatric Bone Marrow Transplant Outpatients – Atlanta, Georgia, 2007. ICHE 2010;31(5):522-527
- Kent County Health Department Dr. Stokes Case
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