Healthcare News & Insights

Heart surgeon at major hospital inadvertently infects 5 patients

As a hospital executive, you know your physicians, nurses and other medical professionals take every possible precaution to protect their patients from contracting any kind of hospital acquired infection. But humans beings aren’t perfect and equipment is fallible, and sometimes things just go wrong, like they did at Cedars-Sinai Medical Center in Los Angeles.

Earlier this year, a heart surgeon inadvertently infected five patients while performing heart vale replacement surgery. And the infection caused four of the five patients — all of whom survived — to require an additional surgery. A very pricey error for the hospital, since it covered the cost of the patients’ care, including follow-up treatment and the related surgeries.

Unusual circumstance

So how did it happen?

The problem is, heart valve replacement surgery requires surgeons to use thick sutures and tie more than 100 knots, which can creates additional stress on the gloves and cause micro tears. The surgeon, in this case, had a skin infection and the micro tears allowed bacteria from the inflammation on his hand to pass into the patients’ hearts, according to the LA times blog.

Of course the hospital investigated, but so did the LA county and California department of public health. In addition, the Centers for Disease Control and Prevention was also consulted on the cases.

While the surgeon still works at Cedars-Sinai Medical Center, he no longer performs surgeries at the hospital.

Zero infection

Like most hospitals, Cedars-Sinai’s goal is to have zero infections. Harry Sax, vice chairman of the hospital’s department of surgery, told the LA Times, “any hospital-acquired infection is unacceptable.”

The incident made the facility question what health conditions should keep surgeons out of the operating room, as well as the effectiveness of the surgical gloves used.

Obviously, surgeons with open sores or known infections can’t operate. But Rekha Murthy, medical director of the hospital’s epidemiology department, brought up the fact that there isn’t a national standard on operating with a skin inflammation or what type of gloves to use, or how often the gloves should be changed during a procedure.

However, now, all surgeons performing valve replacements at Cedars-Sinai are required to change gloves more frequently, and some are wearing double gloves.

Overall Cedars-Sinai has a very good reputation. It performs approximately 360 valve replacement surgeries a year and infections occur in fewer than 1% of cases, which is lower than the national average.


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