What Are Risk Scenarios?
Each Risk Scenario consists of two parts — The Scenario and The Analysis.
Part 1: The Scenario (15 minutes) Read The Scenario and answer integrated poll questions that solicit your approach or feedback to the situation. The Scenario is based on hypothetical situations that showcase emerging risks.
Part 2: The Analysis Review key themes in the Summary, access relevant articles and resources, learn about existing products and discuss the scenario with other participants.
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
Shane Graves, the chief pediatric heart surgeon at St. Michael’s Hospital, closed the door of the hospital room he had just left and stopped to gather himself.
In the room behind him lay the dead body of Garret Easton, a two-year-old boy who had valiantly survived a heart defect and corrective surgery only to have his life swept away by a virulent strain of Methicillin-Resistant Staphylococcus Aureus or MRSA, that somehow, the boy had contracted in this very hospital. “Damn it, Damn it, Damn it!” Dr. Graves said to himself inwardly.
Now Dr. Graves had to make the walk that many physicians must make and never get inured to making. He was the one that had to tell Garret’s young parents that their first and only child was gone.
His mind, normally insightful, analytical and serenely well-informed, had become a cauldron of emotion-fueled thinking. Rage, grief, embarrassment and fear swirled through him.
He wouldn’t blame Richard Easton, the dead boy’s father, if he put his hands around his neck and tried to choke him to death.
Dr. Graves made a left turn, walking as if he were in a nightmare, and went through the swinging doors to the waiting room. When the Easton’s saw his face, they knew, and Jennifer Easton buried her face in her husband’s chest and began sobbing uncontrollably as her husband put his arms around her to comfort her.
The infection that killed Garret Easton had entered the hospital like a thief in the night and evaded what had been fairly sound safety protocols. The staff at St. Michael’s had been educated that MRSA infections are transferred primarily from skin-to-skin contact and that hand washing was mandatory after handling patients or coming into physical contact with them in any way.
The infection was discovered in an elderly patient who had been admitted to intensive care from a nursing home and was receiving respiratory therapy treatments for pneumonia. She had been in ICU for three days when an alert nurse noticed reddening in the patient’s nostrils and what looked like the beginnings of a lesion. Following hospital protocols, the patient’s nose was immediately tested and she was found to have the infection.
Once detected, the hospital’s infection control committee, which consisted of the Infection Prevention Professional, a physician and representatives from administration, nursing, operations (housekeeping and dietary) and pharmacy, was notified of the outbreak. Then every patient in the ICU was tested, in accordance with hospital procedure.
As a result of that testing, two more patients were found to be infected. All three infected patients were placed in specially designated rooms where administration of an intravenous antibiotic was initiated and where additional infection control protocols were put in place. Those measures included contact precautions (use of gowns and gloves by staff and visitors) use of dedicated non-critical care equipment, assignment of dedicated staff to care for the patients with the MRSA infection, control and monitoring of traffic in and out of the patient rooms and focused staff and family education. Assigning the patients to specially designated rooms also allowed for effective environmental and equipment cleaning and decontamination.
It was after the three patients were placed in designated care areas and treatment for the MRSA initiated that the incision in Garret Easton’s chest had shown signs of infection and, that the connection between all the affected patients was determined to be a respiratory therapist who had failed to use proper hand washing techniques after direct patient contact.
Again, following protocols, the infection control committee directed that every patient in the pediatric wing be tested for MRSA. One more patient, a young female on the pediatric wing also tested positive for MRSA infection, but she wasn’t as compromised as Garrett, and was stabilized with the recommended course of an intravenous antibiotic.
Additional precautionary steps taken by the hospital included active infection control surveillance and re-education of staff on infection prevention policies and procedures including the importance of hand washing. The ICU and pediatric wing were vacated and an environmental cleanup was conducted. Unfortunately, it was too late for Garrett Easton, but the infection appeared to be at least under control.
(The Scenario continues on page 2)