A Large Nosocomial Outbreak of Hepatitis C Virus Infections at a Hemodialysis Center

Savey, Anne; Simón, F; Izopet, Jacques; Lepoutre, A.; Fabry, J.; Desenclos, Jean‐Claude

doi:10.1086/502613

Cited by 103 publications

(77 citation statements)

References 52 publications

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“…Water quality, membrane reuse, and infection control are key areas of safety risk, and adverse events have been reported in each area (7)(8)(9)(10)(11)(12)(13)(14)(15). Infection control risks, such as design flaws (9), inadequate hand hygiene, and faulty machine and equipment disinfection (7,8,15,16), have been associated with outbreaks of unusual biopathogens (8,9,13), as well as transmission of vancomycin-resistant enterococcus and hepatitis B and C viruses. The regulations and safety guidelines for water quality, reuse, and infection control are established and readily available (14,17).…”

Section: Dialysis Safety Prioritiesmentioning

confidence: 99%

“…It is possible (although not definite from the survey questions) that the error was caught before initiation of therapy; however, patients also could have been unaware of the errors (6,19). In addition to clinical safety, failure to follow protocol has also contributed to technical mistakes and lapses in infection control (1,2,(4)(5)(6)(7)(8)(9). Among other risks, protocol departures can result in critical errors in dialysis reuse, dialysate composition, and water purification, with catastrophic effects on an entire facility (7)(8)(9)(10)(11)(12)(13).…”

Section: Failure To Follow Policies and Protocolsmentioning

confidence: 99%

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Patient and Facility Safety in Hemodialysis

Garrick

Kliger

Stefanchik

2012

Clinical Journal of the American Society of Nephrology

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SummaryPatient safety is the foundation of high-quality health care. More than 350,000 patients receive dialysis in the United States, and the safety of their care is ultimately the responsibility of the facility medical director. The medical director must establish a culture of safety in the dialysis unit and lead the quality assessment and performance improvement process. Several lines of investigation, including surveys of patients and dialysis professionals, have helped to identify important areas of safety risk in dialysis facilities. Among these are lapses in communication, medication errors, patient falls, errors in machine and membrane preparation, failure to follow established policies, and lapses in infection control. The quality assessment and performance improvement process should include a dedicated safety team to focus on specifically identified areas of risk and to establish outcome goals guided by best practices and agreed-upon measures of success. A safety questionnaire can be given to patients and staff and the responses evaluated to improve understanding of the prevailing attitudes and concerns about safety. By sharing these results, openly acknowledging the challenges, and using a blame-free root cause process to identify action plans, the facility can begin to establish a culture of safety.

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Section: Dialysis Safety Prioritiesmentioning

confidence: 99%

Section: Failure To Follow Policies and Protocolsmentioning

confidence: 99%

Patient and Facility Safety in Hemodialysis

Garrick

Kliger

Stefanchik

2012

Clinical Journal of the American Society of Nephrology

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“…It is frustrating in this setting that although intravenous drug use continues to be the primary mode of transmission of hepatitis C virus (HCV) in the United States and Europe, nosocomial outbreaks of HCV infection continue to be reported [1][2][3]. Such outbreaks are not new, having been extensively reported and analyzed in the setting of hemodialysis and poor infection control when using multidose saline vials, heparin solutions, and pain remediation treatments [4][5][6][7].…”

mentioning

confidence: 99%

Making the Best of a Bad Situation: Early Chronic Nosocomial HCV infection

Santos

Herrine

2010

Dig Dis Sci

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“…The risk of transmission depends on the mechanism responsible, as well as on the prevalence of infected persons. Thus, in addition to use of shared vials for administration of heparin (4), physiological saline solution (5-7) or anesthetics (8,9), procedures carried out with contaminated equipment (10,11) or inappropriate practices of health personnel (12) have been proposed as mechanisms of nosocomial transmission. Molecular analysis of HCV has permitted comparison of different viral sequences to confi rm transmission.…”

mentioning

confidence: 99%