In early 2008 the largest hepatitis C outbreak in U.S. history resulted from nurse anesthetists reusing syringes and medication vials at an outpatient endoscopy clinic, as Carol Potera reports in the April issue of AJN. Five of the nurses relinquished their licenses a year ago when the investigation began, as did two physicians, and the clinic was fined $500,000. Now, Nevada lawmakers are considering new legislation that might prevent another such crisis.

An excellent graphic in the Las Vegas Review-Journal illustrates just how the reuse of medication vials, even with the use of sterile syringes, could contribute to such an outbreak. But a year after the hepatitis C outbreak, a nagging question remains: how and why did five nurse anesthetists violate the basics of infection-control protocols? When they reused syringes and medication vials, were they following orders out of fear of losing their jobs? Or were they unfairly scapegoated in a system without sufficient safeguards?
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