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Infection control lapse contributed to deaths

Infection Control Monitor, October 6, 2006

An outbreak that killed three babies at Wellington Hospital in New Zealand last year has been linked to stressed staff, overcrowding in the neonatal intensive care unit, and a "serious lapse" in infection control, according to a report in the Dominion Post newspaper.

The premature babies died in early 2005 from an aggressive strain of the common bug staphylococcus aureus. An outbreak of gentamicin-resistant staphylococcus aureus was first identified in the unit in April 2004 but a full outbreak was not declared until a year later, after the deaths, according to internal and external reviews of the outbreak released to the newspaper this week. The reviews found the hospital effectively eliminated the infection once the outbreak was declared and it introduced strict infection control and isolation measures.

Wellington Hospital microbiologist Mark Jones, who worked on the internal review, told the newspaper that the combination of cramped conditions, staff stress, and limited acceptance of alcohol hand gels made it "an outbreak waiting to happen."

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