Saline Flush Preparation Tied to Bloodstream Infection in Oncology Clinic

March 12, 2014 | Strategic Insights for Health System


Improper preparation of a saline flush was the common factor among 15 patients of a West Virginia outpatient oncology clinic who suffered a rare bloodstream infection, although many infection control lapses were noted, according to a study of the outbreak in the March 2014 Infection Control and Hospital Epidemiology. The outbreak of Tsukamurella infections, which occurred from September 2011 through May 2012, prompted investigations by the state public health department and the Centers for Disease Control and Prevention (CDC) and is believed to be the first of its kind. The investigations identified lapses including improper storage and reuse of medications from single-use vials; medication preparation next to a sink, raising the possibility of contamination with tap water; and occasional reuse of needles to draw and combine multiple medications, raising the possibility of cross-contamination.

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