Incomplete tissue product tracing during an investigation of a tissue-derived tuberculosis outbreak.

In the United States, there is currently no system to track donated human tissue products to individual recipients. This posed a challenge during an investigation of a nationwide tuberculosis outbreak that occurred when bone allograft contaminated with Mycobacterium tuberculosis (Lot A) was implanted into 113 patients in 18 US states, including 2 patients at 1 health care facility in Colorado. A third patient at the same facility developed spinal tuberculosis with an isolate genetically identical to the Lot A outbreak strain. However, health care records indicated this patient had received bone allograft from a different donor (Lot B). We investigated the source of this newly identified infection, including the possibilities of Lot B donor infection, product switch or contamination during manufacturing, product switch at the health care facility, person-to-person transmission, and laboratory error. The findings included gaps in tissue traceability at the health care facility, creating the possibility for a product switch at the point of care despite detailed tissue-tracking policies. Nationally, 6 (3.9%) of 155 Lot B units could not be traced to final disposition. This investigation highlights the critical need to improve tissue-tracking systems to ensure unbroken traceability, facilitating investigations of recipient adverse events and enabling timely public health responses to prevent morbidity and mortality.

Infection prevention and control core practices: A roadmap for nursing practice.

The CDC continues to stress the urgent issue of increasing microbial resistance. The organization recently joined forces with the American Nurses Association to bring awareness to this issue through an approach that prevents inappropriate antibiotic use and stresses infection prevention.

Serious unintended outcomes associated with cesarean section.

BACKGROUND: Serious unintended outcomes (SUOs) associated with cesarean section (CS), defined in this study as sepsis, endometritis, or wound disruption, occurring during the admission to deliver an infant by CS, or on readmission for wound disruption, are not routinely measured in a manner that continuously evaluates their impact on women's health. METHODS: The Texas Healthcare Information Collection Public Use Data File was used to investigate trends in the diagnosis of SUOs over a 5-year period from January 1, 2010-December 31, 2014. RESULTS: CS-associated SUOs affected 9.24 women for every 1,000 CSs. During the study period, a large decrease in the rate of SUOs occurred (R2 = 0.60). This was potentially influenced by a large decrease in the rate of endometritis (R2 = 0.41). Decreases in the diagnosis of and readmission for CS wound disruption were not as large (R2 = 0.06 and R2 = 0.03, respectively). A large increase in CS-associated sepsis (R2 = .32) was identified. Administrative coded data used to identify SUOs in this study may have utility for the identification of serious unintended outcomes associated with CS at the population level. CONCLUSIONS: Increases in length of stay and utilization of critical care were noted among women affected by CS-associated SUOs. Additional study is needed to determine factors that increase the likelihood of the development of SUO and to evaluate the preventability of these events.

Infection Prevention and Control Core Practices: A Roadmap for Nursing Practice.

In 2017, the CDC released a set of Core Practices focusing on infection prevention and control relevant for care delivered in all settings. These eight Core Practices address foundational elements of practice and should be embedded into every aspect of nursing care and part of every nurse's professional development plan.