By James Girards. A new Sentinel Event Alert was issued this week by the Joint Commissions on Accreditation of Healthcare Organizations - and it will surprise you. A Sentinel Event Alert ["SEA"] is an urgent issue that affects the safety of thousands of patients that JCAHO deems worthy of publishing a document that gets issued to almost every hospital in the country for immediate circulation to the hospital staff. There have only been 51 such alerts in the history of JCAHO - until this week. They usually cover matters of some complexity and highlight new science that would benefit widespread dissemination in order to decrease needless harm to patients. But, this week's alert might surprise you. So, here goes: hospital practices have gotten so poor across the USA that thousands of patients are needlessly exposed to life threatening infections or death because hospital and office staff are reusing syringes and injectible medications on multiple patients. And, its not just one or two crazy hospital workers who slipped through the cracks in the system. A survey of 5,446 healthcare workers is shocking:
"A significant contributing factor to the misuse of vials is the lack of adherence to safe infection control practices and to aseptic techniques within health care organizations. For example, a survey of 5,446 health care practitioners found lapses in basic infection control practices relating to vial use. The results included:
- For single-dose/single-use vials, 6 percent admitted to sometimes or always using vials for multiple patients. [that's 326 people]
- For multiple-dose vials, 15 percent reported using the same syringe to re-enter a vial numerous times for the same patient; of that 15 percent, 6.5 percent reported saving vials for use on another patient. [that's 816 and 53, respectively]
- Of the 51 professionals who reported reusing a syringe to obtain an additional dose from a multiple-dose vial and then leaving it for use on another patient, about half (52.0%) were from the hospital setting."
So, let's go deeper. According to Kaiser Family Foundation, there are 11,756,610 healthcare workers in 2011 in the USA. A lot of those workers don't give injections, so just for the sake of argument let's say that 75% of them do and 25% do not. That's 8,817,458 healthcare workers who give injections. If the study mentioned above holds true for this population then 1,322,619 healthcare workers who are injecting potentially contaminated stuff into their patients exposing the patients to things such as blood-borne bacteria and viruses [think hepatitis and sepsis], septic arthritis and bone destruction, brain infection, spinal cord abcesses, and death.
The SEA cites a study by CDC and CMS that two-thirds of inspected ambulatory surgical centers had lapses in basic infection control practices. Twenty-eight percent of these facilities used medications in single-dose vials for multiple patients.
It has been a decade or more since hospital legal accountability has been reduced or eliminated in many states due to so-called "tort reform" laws. At the time those bills were pending, patient safety advocates said that reducing hospital accountability would take us back to the dark ages of medicine. But, politicians didn't listen. So, here we are. Now, parents can't even be assured that the injection their kiddo is receiving hasn't been used on someone else. Perhaps blood-letting is not far behind....
You can read the full text of the SEA by clicking here.
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