A healthcare worker may have exposed more than 751 infants and 55 coworkers to tuberculosis (TB), a potentially deadly disease, during the 11.5 months she worked with newborns in the nursery and post-partum unit. The employee was found to have symptoms of active TB (the only kind that is contagious) in July 2014 and was tested on August 21, 2014. Infants and coworkers who were in those units between September 1, 2013 and August 16, 2014 are potentially affected.
The impacts of the potential exposure are significant. The goal of ensuring patient safety has been impacted because of the potential exposure of 751 infants (so far identified). Additionally, the goal of ensuring employee safety has also been impacted as 55 coworkers are also potentially impacted (those already screened have not shown any signs of infectious tuberculosis). Because of the close contact required to spread TB, the issue has not been identified as a public health threat. Regulatory agencies are still interested – the hospital has been cited by the Department of State Health Services for issues relating at least in part to infection control that are “an immediate jeopardy to patient safety”. (It wasn’t clear how or if these issues are directly related to the TB exposure but were found in an inspection that occurred as a result of it.) All the patients who have been exposed may potentially require a course of antibiotics, typically six to nine months. Infants under six months are being given the course as a preventive measure. This impacts the patient services goal. All the screening and treatment is being provided by the hospital free of charge, which is an impact to the hospital’s labor and time goal.
Developing the cause-and-effect relationships that led to the goals that were impacted can provide clarity to the investigation and potential solutions. Exposure to TB occurred when an employee with an active infection came to work and was potentially aided by the hospital’s infection control policies or procedures, which may not have been effective in preventing the spread of the disease. It’s unclear how the employee contracted tuberculosis, but she was likely not vaccinated. Although a vaccine against tuberculosis exists, it’s rarely used in US.
A question raised by this issue is why the long period of time during which there was a potential exposure? Tuberculosis can remain latent in the body for months or even years before turning into an active case. (It is only contagious when active.) The employee appears to have passed a routine annual health screening in July 2013 and started showing symptoms at or near her next annual health screening in July 2014. However, she was not tested for the disease until August 21st and appears to have continued work until August 16th. It’s unclear why the delay occurred, and the hospital will surely be looking to ways to minimize patient exposure to workers who may be sick.
The hospital is working with the Texas Department of State Health Services and the Centers for Disease Control and Prevention to screen and treat patients and other healthcare workers that came into contact with the infected worker based on employment and medical records in an extensive outreach campaign. The employee has been placed on leave and is being treated. The hospital is required to submit a corrective action plan to the Texas Department of State Health Services, which should identify corrective actions to issues raised as a result of the state’s inspection and by the Centers for Medicare & Medicaid Services.
To view the impacted goals, cause-and-effect relationships and potential solutions in a Cause Map, or visual root cause analysis, please click “Download PDF” above. Or, click here to learn more.