Healthcare-associated Infections

Outbreaks and Patient Notifications in Outpatient Settings

The following table includes examples of recent outbreaks and patient notification events occurring in a variety of outpatient settings including primary care clinics, pediatric offices, ambulatory surgical centers, pain remediation clinics, imaging facilities, oncology clinics, and health fairs. This is not an exhaustive list but it serves as a reminder of the serious consequences that can result when healthcare personnel fail to follow the basic principles of infection control. Such consequences include: infection transmission to patients, notification of thousands of patients of possible exposure to bloodborne pathogens, referral of providers to licensing boards for disciplinary action, and malpractice suits filed by patients.

These events are preventable, yet they continue to occur. Facilities and healthcare personnel are urged to review the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care and its accompanying Infection Prevention Checklist to assess the policies and procedures in their facility as well as their own personal practices to assure they are in accordance with evidence-based guidelines and to prevent patient harm.

Setting	Year Investigated	Pathogen(s)	Infection(s)	Patient notification performed (# notified)	Infection Control Breaches Reported
Urology Clinic [1]	2011	N/A*	N/A*	Yes (101)	1) Single-use needle guides (for prostate biopsy) used for >1 patient
Pediatric Clinic [2]	2011	N/A*	N/A*	Yes (Not reported)	1) Syringe reuse (i.e., using the same syringe to administer influenza vaccine to >1 patient)
Pain Remediation Clinic [3]	2010	Hepatitis C Virus	Hepatitis	Yes (>2,000)	1) Syringe reuse (i.e., double dipping)†
Heath Fair [4]	2010	N/A*	N/A*	Yes (50)	1) Same fingerstick device used on >1 patient to obtain blood samples for blood glucose monitoring
Outpatient Radiology Facility [5]	2010	Streptococcus salivarius	Meningitis	No	1) Healthcare providers did not wear facemasks when performing spinal injection procedures 2) Contents from single-dose vials used for >1 patient
Allergy Clinic [6]	2009	Mycobacterium abscessus	Skin and Soft Tissue Infection	No	1) Inappropriate selection and dilution of skin disinfectant
Hematology-Oncology Clinic [7]	2009	Hepatitis B virus	Hepatitis	Yes (2,700)	1) Medication preparation in a blood processing area 2) Contents from single-dose vials and saline bags used for >1 patient
Outpatient Pain Clinic [8]	2009	Staphylococcus aureus	Bloodstream Infection Meningitis Epidural/Presacral Abscess	Yes (110)	1) Syringe reuse (i.e., double dipping)† 2) Contents from single-dose vials used for >1 patient 3) Healthcare providers did not wear facemasks when performing spinal injection procedures
Primary Care Clinic [9]	2009	Staphylococcus aureus	Joint Infection	No	1) Mishandling of multi-dose vials used for >1 patient (e.g., handling in the immediate patient treatment area and failure to store according to manufacturer instructions) 2) Inadequate hand hygiene 3) Incorrect cleaning and disinfection of medical equipment
Cardiology Clinic [10]	2008	Hepatitis C Virus	Hepatitis	Yes (1,205)	1) Syringe reuse (i.e., double dipping)†
Pain Remediation Clinic [11]	2008	Klebsiella pneumoniae, Enterobacter aerogenes	Bloodstream Infection	No	1) Contents from single-dose vials used for >1 patient 2) Lack of hand hygiene before procedures 3) Not appropriately cleaning the injection site prior to injection
Ambulatory Surgical Center (single-purpose endoscopy center) [12]	2008	Hepatitis C Virus	Hepatitis	Yes (>50,000)	1) Syringe reuse (i.e., double dipping)† 2) Contents from single-dose vials used for >1 patient
Obstetrician/ Gynecologist Office [13]	2007	N/A*	N/A*	Yes (36)	1) Syringe reuse (i.e., using the same syringe to administer influenza vaccine to >1 patient)
Multiple Gastroenterology Clinics [14]	2007	Hepatitis C Virus, Hepatitis B Virus	Hepatitis	Yes (4,490)	1) Syringe reuse (i.e., double dipping)† 2) Contents from single-dose vials used for >1 patient
Pediatric Oncology Clinic [15]	2007	Polymicrobial	Bloodstream Infection	No	1) Contents from single-dose vials used for >1 patient 2) Predrawing saline flush solutions
Dermatology Office [16]	2007	N/A*	N/A*	Yes (13,500)	1) Medical equipment (i.e., scalpels, gloves, syringes, and suture material) designed and intended to be used on a single patient used on >1 patient.

* Infection control breach, not infections, prompted patient notification. It is not known if any infections resulted from the unsafe practices.

† Double Dipping: Syringe that had been used to inject medication into a patient, reused to enter a medication vial. The syringe is discarded but contents from that vial, which were contaminated through reuse of the syringe, are then used for subsequent patients.