Becker's Clinical Quality & Infection Control

10 INFECTION CONTROL & PATIENT SAFETY MD Anderson patient died after contaminated blood transfusion, CMS says By Mackenzie Bean A 23-year-old leukemia patient died aer receiving a contaminated blood transfusion at MD Anderson Cancer Center, according to a CMS report made public June 24 and cited by the Houston Chronicle. e report came two weeks aer news broke that CMS found serious care deficiencies at the Houston-based hospital. Regulators investigated MD Anderson aer the hos- pital reported an adverse event involving a blood transfusion in December 2018. e specific circumstances of the event were not originally made public. e CMS report said a female patient with leukemia died two days aer receiving a blood transfusion contaminated with bac- teria. e report also noted the patient had serious complications before receiving the transfusion. "While it is unfortunate that the CMS sur- veys resulted from an adverse patient event, we recognize and embrace the opportunity to further enhance and improve our patient care efforts and robust safety measures," MD Anderson said in a statement on its website. "We take this feedback seriously, and we already have implemented changes into our clinical practice." e hospital implemented new safeguards for blood transfusions and is providing ongoing education on blood administra- tion procedures, among other efforts. MD Anderson also sent CMS a correction plan to address deficiencies June 21. Regulators are expected to revisit the facility in July to determine if the hospital has re- gained compliance to federal standards. e hospital is still participating in Medicare and Medicaid programs. n Nurse understaffing linked to higher HAI risk By Anuja Vaidya N urse understaffing increases the risk of healthcare-associated infec- tions in hospital units, a study published in the Journal of Nursing Administration found. Understaffing increases workloads for individual nurses, which can ulti- mately affect infection prevention practices and surveillance activities. "As they often serve as coordinators within multidisciplinary healthcare teams, nurses play a critical role in preventing HAIs, which is a top priority for improving quality of care and reducing hospital costs," said study lead author Jingjing Shang, PhD, an associate professor at Columbia Nursing. Researchers from New York City-based Columbia University School of Nurs- ing examined unit-level data from large urban hospital systems between 2007 and 2012. The study included data for more than 100,000 patients. The study showed 15 percent of patient days had one shift where regis- tered nurses were understaffed, and 6.2 percent of patient days had both day and night shifts where RNs were understaffed. Researchers found patients in units with RN understaffing at both day and night shifts were 15 percent more likely to develop HAIs on or after the third day, compared to patients in units that were adequately staffed for both shifts. n Over 60 patients allege sterilization negligence at Porter Adventist Hospital By Anne-Marie Kommers S ixty-seven patients and 22 spouses filed a lawsuit June 15 against Porter Ad- ventist Hospital in Denver, claiming the hospital caused infections and death due to improper equipment sterilization, according to The Denver Post. The lawsuit came roughly a year after hospital officials found a sterilization breach occurred at the hospital between July 21, 2016, and Feb. 20, 2018. Complaints include one patient who had seven knee surgeries due to ne- crotic tissue and an infection he allegedly developed after surgery at Porter Adventist in 2017. The bacteria included a particular type usually found in a pregnant woman's vagina or rectum. Another patient died after developing an infection, sepsis and other complications from surgery on his femur and hip, the lawsuit claims. Porter Adventist shared the following statement with Becker's: "We acknowledge the concern of these patients and are aware of exist- ing lawsuits stemming from a review by [the Colorado Department of Public Health and Environment] of the pre-cleaning process of surgical instruments prior to sterilization, which was identified in February 2018," a spokesperson said. "To protect the privacy [of] all involved, we will be addressing this matter through the legal process, which is underway. As an outcome of the CDPHE investigation, we continue to provide reports to CDPHE that confirm Porter Adventist Hospital continues to meet the steril- ization process guidelines of CDPHE." n

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