A dozen hepatitis infections traced to one anesthesiologist

By: July 28th, 2010 Email This Post Print This Post

A report published in the July issue of Gastronenterology sheds some light on an outbreak of hepatitis B and C in New York City in 2006.

The report linked six cases of hepatitis B and six more cases of hepatitis C to one outpatient endoscopy center, along with an additional case of hepatitis C at a separate clinic, to one healthcare worker — a contract anesthesiologist who practiced at both facilities.

The report found the anesthesiologist had reused single-dose vials on multiple patients, which is strictly forbidden according to CDC guidelines.

“All affected patients in both clinics received propofol from anesthesiologist 1, who inappropriately used a single-patient-use vial of propofol for multiple patients,” the authors wrote. “Reuse of syringes to redose patients, with resulting contamination of medication vials used for subsequent patients, likely resulted in viral transmission.”

The authors advise physicians to educate all staff members, including anesthesiologists, on safe injection practices and the use of single-dose vials, and supervise procedures to ensure best-practices are being followed.

July 14 issue of Joint Commission Online says surveyors will observe injection practices to ensure proper procedures. All accredited facilities are required to follow guidelines for infection prevention according to IC.01.05.01, EP 1.

For educational material, the “One and Only Campaign” recently released a ten-minute video to educate healthcare workers on safe injection practices. This week the video was featured as the Immunization Action Coalition’s (IAC) video of the week. You can also read an archive of posts on safe injection practices by clicking here.

Comments

How absolutely horrifying that the very people we put our trust in as physicians are the same people who do not follow proven protocols. How dare he/she think that it was OK not to follow the proper procedure.

I understand how he made his mistake. It should also be reinforced that even though IV fluid flows down, the ports may be contaminated with the patient’s blood. Too often nurses and physicians consider them clean. Never say such an assumption can’t happen in your own practice. That’s why I read these letters and blogs and journals…

By Ken Rashid, M. D. on July 31st, 2010 at 3:21 pm

Hospitals must carefully observe techniques by contract/visiting anesthesiologists. There was one hospital at which I consulted where a locum tenens anesthesiologist infected 15 patients with Hepatitis C, by using the exact same process as described in the article. Somehow being a “visitor” allows the anesthesiologist to vary from established protocol.

 

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