Infection Control

Horror stories highlight safety and IC faux pas

Briefings on Infection Control, November 1, 2009

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When you work in the healthcare field, you accumulate plenty of stories. Pretty soon, you begin to think you’ve seen and heard it all.
For those who have a particular focus on infection prevention and OSHA training and regulations, keen eyes pick out even the smallest and most innocent violations on an often routine basis.
Of course, there are also the more egregious ones, which usually serve as a more powerful reminder to staff members that these regulations are no joke. Infection prevention often crosses over into employee safety and health, particularly regarding personal protective equipment (PPE) and bloodborne pathogens. Many of these horror stories put both patients and employees at risk because of subpar IC procedures.
But these horror stories are not intended to scare you. Rather, they serve as a learning and training opportunity for you and your staff members to prevent these errors or at least know how to mitigate them if a similar situation arises.
Read for yourself and see whether these horror stories might serve as an eye-opener or an IC training opportunity.

One good reason to wear PPE
If you have employees who are cavalier or forget-ful about wearing PPE, this story will make them look at gloves, gowns, and masks in a whole new light.
Margaret S. Lebo, RN, IC and quality improvement coordinator at Martha Jefferson Outpatient Surgery Center in Charlottesville, VA, relays a story from a previous facility that even she could hardly believe.
Lebo witnessed an “ornery” and “somewhat scatterbrained” surgeon perform a colonoscopy while wearing just one article of PPE: gloves. For this particular procedure, the surgeon should have been wearing a gown and a mask as well. While attempting to biopsy the patient’s colon, the long, flexible forceps began swinging around, hitting the surgeon and tracking feces on his scrubs and arms. Becoming more and more frustrated, the surgeon eventually held the long arm of the biopsy forceps in his mouth to stabilize it, Lebo says.
“It was as if he didn’t have enough hands to control the scope and the biopsy and didn’t even realize that he had put this feces-saturated biopsy forceps into his mouth until I screamed at him,” she says. “Then he denied that he had done it.”
The doctor continued to deny any wrongdoing even after the procedure was over, but “would have seen it when he looked in the mirror the next time because there was a diluted light brown feces streak across his cheeks to prove it,” she says.
“Obviously, if he had used PPE as recommended by
our facility, it wouldn’t have happened,” Lebo says. “But because he was an ornery, highly experienced older surgeon, he didn’t take advice from a younger, less experienced nurse.”

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Infection Control.

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