Photo by ad-vantage / Vanessa Agressti, from Flickr.
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?
In “Infection Control: Whose Job Is It?” Potera writes that the CDC “identified several unsafe nursing practices that likely contributed to the outbreak, including inadequate handwashing between patients, reusing syringes, and using single-use medication vials with multiple patients. Two nurses told the CDC investigators that clinic managers told them to reuse syringes.” Nine people were known to be infected, and there may be 100 more.
After the first anniversary of what one editorial writer called “one of the lowest points in the history of health care in Southern Nevada,” AJN asks nurses: why did this happen?
—Joy Jacobson, managing editor, AJN
Want More on the Outbreak?
Extensive coverage of the Nevada hepatitis outbreak and the subsequent investigations and legal proceedings, both criminal and civil, have been provided by the Las Vegas Sun (archives are here) and the Las Vegas Review-Journal (archives are here and here). The CDC’s report on the outbreak is here. 
I think peer pressure is another important element of this story. New nurses learn quickly from their preceptors, the way you’ve learned to do something in school is quite different from how it’s done in the “real world”. For instance, when is the last time you’ve seen a manual blood pressure done correctly? I’ve seen how nurses can make the work place pretty unpleasant for those that try to follow protocols, especially if it takes more time. Nurses need to know they can and should stand up for what is right. The problem is they are frequently discouraged to do so because of poor support from administration and colleagues. A great place to start is in nursing schools. Students should be aware of these kinds of situations and be taught strategies to address them.
In response to the last post, I would totally agree, except that we have clinicians practicing at less than professional levels. Sadly, patients as consumers do need to take some responsibility to effect the quality of their healthcare. Just neglecting to wash your hands can be a “deadly mistake” if you pass along a resistant infection. Patients can help reduce the possibility of getting a hospital acquired infection by asking clinicians if they have washed their hands.
I am only a civilian (albeit a senior editor here at AJN), but I’m alarmed at the thought that “patients are starting to take on some of this responsibility as well.” I don’t think patients should be “responsible” for ensuring that health care professionals don’t make deadly mistakes. It might be in a patient’s best interest to keep a close eye, to learn as much as possible, and to do what one can. But that’s not the same thing as having responsibility. No, I want my caregivers to be fully responsible professionals, with all that that entails. Otherwise they have no business practicing. Period.
I appreciate your comments about nurses’ responsibility for infection control. Patients are starting to take on some of this responsibility as well. There’s an advocacy organization called HONOReform, the Hepatitis Outbreaks National Organization for Reform. It describes itself as “the only national advocacy organization dedicated to making injection procedures – from chemotherapy treatment to flu shots – safe for all patients” (www.honoreform.org). It was founded by a woman who contracted hepatitis C as a patient.
This situation revealed obvious breaches in many infection control protocols, some glaring and some a bit more subtle. In my work I observe clinical practice and regularly see clinicians fail to follow known infection control protocols. Lapses such as failing to wash hands, not cleaning the access port on an IV set prior to entry, and allowing IV tubing ends to scrape the environment and then reattach are only a very few. Clinicians are taught to wash their hands and to perform other infection control functions but numerous studies have found limited compliance to these simple measures that can greatly improve patient outcomes. Until clinicians take full responsibility for the outcome of their care these situations will continue to occur. Staff often blame such lapses in care on being too busy. This cannot remain an excuse any longer. Patients lives and ultimately our jobs depend on improving the quality of healthcare. How do we accomplish this?
Education, compliance monitoring, and more education can affect change but the staff have to buy in to the idea that every move they make- makes a difference, and help monitor each other. This does not have to be in an atmosphere of blame, it can be as a promotion of a culture of safety. If your mother, father, child or other loved one was in that hospital bed, wouldn’t you hope their care to be stellar, 100% of the time?
I totally agree with Beth. Last year I viewed a web symposium put on by the CDC on needle re-use. I was shocked to see that this happens, and think any nurse who would do this deserves to have his/her license revoked. This is clearly a huge breach in infection control practice and goes counter to everything I have ever heard.
You should whistleblow on your boss if told to do this….call the local papers and the media. This is outrageous. Ask the boss to take an injection with your used syringe and see how they would react.
Thanks for your comments. Yes, many factors were involved, and physicians had licenses revoked and the endoscopy clinic was closed (and 5,000 people have filed suit against the clinic). The Government Accountability Office released a report on Monday on health care-associated infections in ambulatory surgical centers(http://bit.ly/T6gvJ), saying that having investigated similar centers in Nevada, it found that “such lapses are not isolated events but indicate a larger, more widespread problem.” The report calls for more “nationally representative data.”
But that data won’t necessarily tell us how and why these “systems errors” happen. I’d love to hear more from nurses — why do you think this happened? Most nurses probably feel as Beth does in her comment here, that there would never be a situation in which it would be appropriate to reuse a syringe. So what would you do if your boss told you to do so?
I’m baffled as to how this could happen. I can’t think of a single situation where it would be appropriate to reuse a syringe on multiple patients, can you?
As for the nurses possibly afraid of being fired for refusing to reuse a syringe – There’s absolutely no reason anyone should do something unsafe simply because they are afraid of being fired. Isn’t that what you have state nursing boards are for – to protect you against such situations?
It sounds as though there were probably numerous factors identified by authorities, not to mention the existence of many more personal factors that came into play, a sort of Perfect Storm scenario, thus making it very difficult to redress in toto. One can only hope that the physicians and managers identified in this case were also meted out their due in exactly the same proportion to that experienced by the culpable nurses.