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Multiple injection safety violations led to NJ outbreak

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August 1, 2019

By Jay Kumar, PSQH

Multiple violations of injection safety and infection prevention practices contributed to a 2017 outbreak of septic arthritis at a New Jersey outpatient facility, according to an investigation published in Infection Control & Hospital Epidemiology.

Investigators found 41 patients with osteoarthritis contracted the rare infection following injections in their knee joints, with 33 requiring surgery to remove damaged tissue. The article, published in the journal for the Society for Healthcare Epidemiology of America, said investigators found practices including lack of hand washing to inappropriate reuse of medication vials. The name of the facility was not revealed in the article.

“This large, costly outbreak highlights the serious consequences that can occur when healthcare providers do not follow infection prevention recommendations,” said Kathleen Ross, an epidemiologist with the New Jersey Department of Health, in a press release. For 31 affected Medicare patients alone, there were more than $5 million in charges claimed for treatment.

There were initial reports from three cases from a local hospital to state and local health departments and multiple complaints were made directly to the facility in March 2017. As a result, the facility voluntarily stopped performing procedures. A state infection prevention assessment team found 41 cases along with multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection processes.

A team of medical and public health professionals from state and county health departments collected medical records and self-reported data and then, joined by the New Jersey Division of Consumer Affairs, conducted an unannounced visit to the facility. The visit included staff interviews, medical record reviews, evaluation of regulated medical waste handling, and observation of mock procedures performed by the staff while the facility was closed.

Before the facility was reopened, state officials provided recommendations from the CDC’s 2016 Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. An infection prevention consultant was recommended to review practices and assist with changes. No additional case were reported after the recommendations were implemented.

The outbreak points to the need for improved training in infection prevention for all healthcare personnel on an ongoing basis, according to the article.

“Outbreaks related to unsafe injection practices indicate that certain healthcare personnel are either unaware, do not understand, or do not adhere to basic principles of infection prevention and aseptic techniques, confirming a need for education and thorough implementation of infection prevention recommendations,” Ross said.




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