​Researchers at a tertiary teaching hospital in Auckland, New Zealand, found that microorganisms with the potential to cause infection were sometimes injected into patients during the bolus administration of intravenous drugs during anesthesia. A study published in the April 2016 issue of Anesthesiology describes the use of a 0.2 micrometer filter unit to capture syringe residue for later study—with the expectation that the filter membranes housed in the unit would trap any inadvertently introduced microorganisms—during anesthesiologists' administration of intravenous bolus medications. Researchers isolated microorganisms from the captured material including Staphylococcus capitis, Staphylococcus warneri, Staphylococcus epidermidis, Staphylococcus haemolyticus, Micrococcus luteus/lylae, Corynebacterium, and Bacillus species. Contamination was identified in 19 (6.3%) of 300 cases managed by 23 anesthesiologists between August 2013 and June 2014. The researchers acknowledged that the extent to which introduction of microorganisms from the bolus injection of intravenous drugs might contribute to postoperative infections is not yet clear; the study did not identify either the exact sources of contamination, or the aspects of anesthesiology practice that would need to be modified to prevent contamination. However, citing this study and other emerging data demonstrating that inadvertent lapses in aseptic technique by anesthesiologists may be an important contributor to postoperative infections, the researchers called for reinforcing "the importance of meticulous aseptic technique in administering intravenous injections, particularly when using high stakes access points, such as central venous catheters and peripherally inserted central catheters."

HRC Recommends: Healthcare-acquired conditions are a dangerous and costly problem for patients and organizations alike; postoperative infections constitute a substantial proportion of such events. Although the healthcare profession has made progress in improving patient safety by reducing preventable hospital-acquired conditions, more work must still be done. Risk managers may wish to make medical staff and patient safety leadership aware of this study to prompt examination as to whether practices in any particular specialty may contribute to healthcare-acquired infections.