Becker's Clinical Quality & Infection Control

12 INFECTION CONTROL & PATIENT SAFETY Seattle Children's fixes mold-related violations that killed 1 patient By Ayla Ellison C MS found patient safety violations at Seattle Children's hospital related to mold detected in its operating rooms in May, local TV station KING- TV reported. CMS planned to terminate the hospital's Medicare and Medicaid contracts due to the violations. However, Seattle Children's upgraded its air filtration system, and CMS notified the hospital Aug. 12 it would retain the contracts. e hospital closed its 14 main operating rooms May 18 aer tests revealed traces of Aspergillus mold in several operating rooms and equipment storage rooms. Over the past two years, the mold led to one patient's death and five other infections, according to KING-TV, which cited a statement from Seattle Children's. Aspergillus is a common mold that most people breathe in every day without adverse effects. In rare cases, people with weakened immune systems or lung diseases could develop health issues from the mold spores, according to the CDC. The patients who developed Aspergillus infections after exposure to the mold at Seattle Children's were at higher risk of infec- tion due to medical procedures they had, the hospital told KING-TV. Aer the mold was detected at Seattle Children's in May, hospital officials reported the issue to the Washington State Department of Health. e department performed a three-day on-site survey of the hospital in late May and found more than two dozen violations of federal regu- lations and hospital policy, including failure to properly maintain air filtering systems that fed to operating rooms, according to KING-TV. Seattle Children's made several changes to address the deficiencies. e hospital switched to an updated and sanitized air handler, implemented a new cleaning process that uses ultraviolet light to disinfect surfaces, installed a new humidification system, and sealed poten- tial sources of air leaks in operating rooms, according to e Seattle Times. e hospital reopened its main operating rooms July 4. At a news conference July 3, Seattle Children's CMO Mark Del Beccaro, MD, said daily air-testing results showed the operating rooms were safe, according to e Washington Post. n Global measles cases at 13-year high By Anuja Vaidya W ith measles cases spreading rapidly worldwide, new data from the World Health Organization shows that there have been more cases in the first six months of 2019 than in any year since 2006. From Jan. 1 through July 31, 182 countries have reported 364,808 measles cases to WHO, up from 129,239 measles cases reported in the same period last year. For all of 2018, a total of 353,236 measles cases were reported to WHO. The Democratic Republic of Congo, Madagascar and Ukraine have reported the highest numbers of cases this year. Major outbreaks have also been reported in Angola, Cameroon, Chad, Kazakhstan, Nigeria and the Philippines. The United States has reported 1,241 measles cases, as of Sept. 5, the highest number of cases reported in the country since 1992. In the WHO European region, about 90,000 cases have been report- ed this year, more than the total of 84,462 for all of 2018. WHO advised that everyone keep measles vaccinations up to date and take the two doses required for protection. People are also urged to check their vaccination status before traveling. n Patient waited 20 hours to receive urgent test, surgery at Pennsylvania hospital By Anne-Marie Kommers A patient with a condition that can cause loss of a testicle had to wait nearly a day to undergo testing and surgery at Penn State Milton S. Hershey (Pa.) Medical Center, according to PennLive.com. The patient arrived at the medical center Feb. 14, 2019, with severe pain in his back, side and scrotum, according to a Pennsylvania De- partment of Health report. A physician recommended an ultrasound test to see if the patient had testicular torsion, a condition that requires quick surgery to avoid loss of a testicle and infertility. Yet the physician did not indicate the ultrasound's urgency on the electronic order. The ultrasound was not performed until the next day, about 20 hours after the patient came to the medical center. The patient underwent surgery two hours after the ultrasound, at which point his testicle was removed. The state health department faulted the medical center for the incident. The medical center must implement a correction plan to improve future responses to urgent patient care. Penn State Health did not respond to Becker's request for comment. n

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