Outbreak Column 9: Endoscopy-related outbreaks

Outbreak Column 11: Consequences of outbreaks; lessons for healthcare workers and infection prevention and control teams

“…Providing a safe system does not of itself guarantee safe practice. I have argued previously that when outbreaks happen there can be either a failure of process or a failure to follow process (Curran, 2013b). When there is a pre-meditated intention to deviate from a process this is known as a violation; this is usually deemed an "unsafe act".…”

“…So to the second outbreak in this column; given the specifics of the outbreak that resulted in the HCWs spending time in a US jail, it is only proper that a recent blood-borne virus (BBV) outbreak involving a multi-dose vial is included in this column. Despite having included nosocomial BBV transmission in Outbreak Column 4 and a little in Outbreak Column 9 (Curran, 2013a(Curran, , 2013b, it is still easy to find a new paper which presents something new to an apparently unbelievably incorrigible problem. Once again the setting is an endoscopy clinic.…”