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October 8, 2010

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Health worker’s virus infection was “entirely preventable”

A health-care worker contracted the hepatitis C virus following a needlestick injury at a Worcestershire hospital.

Worcester City Magistrates’ Court heard that the worker had only been in training with Worcestershire Acute Hospitals NHS Trust for three weeks, when the incident took place in February 2007. She was instructed to take blood from a patient known to be infected with hepatitis C, but whose condition was not known to the worker.

After taking the sample, she had difficulty reaching the sharps bin to dispose of the needle because other equipment was blocking her way. She thereforeplaced the needle on the nearest work surface and began dressing the patient’s needle wound. As she reached for a tissue to help dress the wound, she caught her wrist on the needle.

SHP is unable to publish the location of the hospital where the incident took place owing to patient confidentiality.

The HSE’s investigation found that the worker was not supervised during the procedure. Despite action taken to counter the infection from the injury, she was subsequently diagnosed with symptoms of the virus.

In May 2008, the Trust was issued four Improvement Notices, which required it to provide staff with adequate training, review and monitor safe working practices, and put in placeimplement adequate controls.

HSE inspector Jan Willets said: “For staff regularly taking blood from patients, the risk of infection with the hepatitis C virus from a contaminated needle is greater than for any other blood-borne virus.

“This infection was entirely preventable. The risks and controls are well-known and the Trust should have had an effective safe system of work in place. It should have ensured an inexperienced health-care worker was appropriately supervised, aware of the risks to her health from her work with this patient, and the precautions to be taken.

“There are lessons for other Trusts who should check they have appropriate arrangements in place, including identification of high-risk patients, using sharps disposal containers at the point of use, adequate supervision and training systems, and an implemented policy on the use of safer needles, devices and gloves.”

Worcestershire Acute Hospitals NHS Trust appeared in court on 6 October and pleaded guilty to breaching s2(1) of the HSWA 1974, and reg.6 of the Control of Substances Hazardous to Health Regulations 2002, for exposing an employee to the risk of a substance hazardous to their health. It was fined £12,500 and ordered to pay £9000 in costs.

Following the hearing, the Trust’s chief executive, John Rostill, said: “We very much regret the injury that occurred to this member of staff and would like to apologise once again to the individual involved.€ᄄ €ᄄ“Following the incident, the Trust cooperated fully with the HSE and carried out a full investigation into the circumstances that led to the event. On this occasion, the Trust accepts it fell below the health and safety standards expected. €ᄄ

€ᄄ“An immediate plan of action was put in place and we are confident that the necessary investment and improvements have been made to minimise the risk of such an incident happening again. The safety of our staff and patients is our top priority.”
 

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Paul
Paul
11 years ago

As the patient is not identified, why is patient confidentiality being used as an excuse not to name the hospital?