by Kim Smiley
Testing is still ongoing, but at least 31 people have contracted hepatitis C from contaminated syringes at a New Hampshire cardiac catheterization lab. A previous blog discussed the outbreak when it was initially announced that four patients who had used the same cardiac catheterization lab had tested positive for the same strain of hepatitis C, but more information has been released and the Cause Map should be updated to incorporate all the relevant details. One of the strengths of a Cause Map, a visual root cause analysis, is that it can be updated relatively quickly to document important information as it becomes available. In this example, investigators are continuing to work to understand the issues involved, but two new significant pieces of information should be added to the Cause Map.
The source of the hepatitis C has been determined by investigators. Investigators found that a medical technician with hepatitis C contaminated syringes that were then used on patients. The medical technician is a drug addict who used the syringes because they were filled with Fentanyl, an anesthetic far more powerful than morphine. Hepatitis C is spread through blood to blood contact so syringes contained with hepatitis C are a major health hazard that are capable of spreading the disease. The syringes were not secured so he was able to attain them. He then used them, refilled them with saline or another liquid and replaced them without any other member of the staff noticing.
Investigators have also learned that the medical technician responsible for the contamination has worked in 18 hospitals in seven other states during the last 10 years. It’s not known when the medical technician contracted hepatitis C, but investigators believe he had a positive test for hepatitis C in June 2010. This means that the investigation needs to be expanded and that many more people may need to be tested.
This article contains information about what facilities the medical technician worked at and the timeline for his employment. To view an updated high level “Cause Map”, click here.