Photo by ad-vantage / Vanessa Agressti, from Flickr.

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 hereBookmark and Share