Becker's Clinical Quality & Infection Control

5 YEAR IN REVIEW Infection Control in the US: 2015 Year in Review By Heather Punke In a year when quality and infection control in healthcare has been top-of-mind for healthcare executives as these two elements are increasingly tied to their organizations' bottom lines, it was difficult to choose just five events to highlight in this "year in review" piece. But the Becker's Clinical Quality and Infection Control editorial team did just that. For reference, we did something similar in the middle of 2015. In that piece, we listed the following five stories: • Superbug infections linked to duodenoscopes • Hospital Compare star ratings launch • Risk of low-volume surgeries uncovered • Ebola treatment and preparation in the U.S. • Antibiotic resistance in focus Building on those, here are five more infection control and patient safety stories from 2015 that affected hospitals, resulted in changed processes or uncovered new safety risks. ey are presented in no particular order. Plague on the rise Even though many people consider the plague to be a medieval problem, the U.S. has seen several plague cases within its borders this year. e plague is caused by the bacterium Yersinia pestis and generally spreads to humans when they are bit by a rodent flea or they handle an animal with the plague. According to the CDC, 16 cases of plague have been reported in the U.S. through Nov. 16, and four of those people have died. at is well above the usual number of U.S. plague cases: According to CDC data, the annual number of plague cases has ranged from one to 17 between 2001 and 2012, with the median being just three cases per year. "It is unclear why the number of cases in 2015 is higher than usual," the CDC said in a report issued at the end of August, but it did encourage healthcare workers to consider a plague diagnosis when patients present with common signs or symptoms of plague, have traveled to the western U.S., and have been in proximity with rodents and their habitats or with ill domestic animals. Fortunately, since the dawn of the antibiotic era, plague mortality has fallen from as high as 93 percent down to 16 percent. e key to survival is early treatment with an antibiotic such as aminoglycosides, fluoroquinolones or doxycycline. Misdiagnosis under the microscope Misdiagnosis and diagnostic errors were thrust into the national spotlight in September when the Institute of Medicine released its report "Improving Diagnosis in Health Care." To quote the IOM, "Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences." e report estimates that diagnostic errors account for 6 to 17 percent of hospital adverse events and about 10 percent of patient deaths. As such, ensuring accurate diagnoses is a major patient safety issue for physicians and provider organizations to address. e IOM report also stresses the importance of measuring diagnostic errors in healthcare so the industry can establish the frequency of the problem, assess education and training efforts and create a framework for accountability, among other benefits. However, as experts pointed out in a JAMA viewpoint article in November, doing so can be difficult. "Diagnostic errors are particularly difficult to measure accurately," the JAMA viewpoint piece reads, because the diagnostic process is so complex. "Developing good measures will require investments in research and the agreement of stakeholders to use the best measures."

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