A nurse in a Texas hospital mistakenly believed saline flush prefilled syringes could be reused in separate patients' intravenous lines, which led to a hepatitis C transmission in 2015, according to a CDC Morbidity and Mortality Weekly Report released Friday.
After coworkers observed the nurse leaving partially filled syringes near a computer work station, the hospital investigated the practice in collaboration with state, regional and local health departments and the CDC in October 2015.
In an interview, the nurse reported reusing syringes in the previous six months, "erroneously believing that this was a safe, cost-saving measure if no fluids were withdrawn into the syringe before injection of the saline flush," according to the report.
Sign up for our FREE E-Weekly for more coverage like this sent to your inbox
The hospital notified patients of the risk of bloodborne infections and offered free screenings for patients who may have been treated by the nurse during the nurse's employment from April 2014 to October 2015.
Of the 392 patients who were potentially exposed, 182 (46 percent) completed all recommended testing. Those tests revealed one patient contracted hepatitis C as a result of the inappropriate reuse of saline flush syringes.
"This investigation illustrates a need for ongoing education and oversight of healthcare providers regarding safe injection practices," the report concludes. "Hospital and other settings where injections are prepared and administered should perform routine audits. Syringe reuse, if identified, should be immediately corrected and patient notification should be included as part of the institutional response."