DOME home
Search Dome
A publication for all the members of the Johns Hopkins Medicine family Volume information



Have a Hunch? Report It.

Lisa Maragakis helped unmask a culprit catheter responsible for bloodstream infections.

A certain cleaning solution. A water gun-like device for cleaning wounds. Several models of a bronchoscope. Thanks to some astute detective work on the part of JHH staff, these items were found to cause patients harm and then removed from circulation.

The latest safety problem began in the spring of 2004 with a suspicious spike in blood stream infections in the pediatric intensive care unit. An infection control team soon was on the case, but months later, there still was no smoking gun.

“The staff focused on best safety practices, and they were following infection control procedures to the letter,” recalls Lisa Maragakis, a physician on the team.

Soon, though, Karen Bradley, an infection control nurse, heard about similar cases at national meeting. The common denominator: new catheter valve devices, which, because of their design, may have been breeding grounds for infection.

Back at Hopkins Hospital, Bradley discovered that in the PICU a new catheter device, similar to those discussed at the meeting, had in fact been introduced in April 2004 at precisely the moment the infection rate started climbing. The device, a new high-tech positive pressure mechanical valve, and others like it, have ridges in the screw-top mechanism that can catch blood or other fluids. An opaque cover made it impossible to see if fluids were effectively flushed through and cleaned out between procedures.

The infection control team immediately ordered a return to the old valve, and in the PICU, bloodstream infections dropped to baseline rates. The improvement was so dramatic that in February 2005, Trish Perl, director of Hospital Epidemiology and Infection Control, alerted the entire hospital, the FDA and the federal Centers for Disease Control.

Since then, a new system has been put into place that makes it possible for staff throughout JHM to report suspicions concerning equipment or medications to their patient safety officers.

“Our experience underscores how advances in technology designed to improve health care may also have hidden risks that can only be identified by paying close attention to what happens after the technology is put into practice,” notes Perl.

Perl, Maragakis, Bradley and others published their findings in the journal Infection Control and Hospital Epidemiology on Jan. 6. Since then, e-mails have come in from around the country. “Our thanks,” wrote a nurse at St. Luke’s Episcopal Heath System in Houston, “to the wonderful team at Johns Hopkins that alerted the rest of the medical community regarding this device and its potential for patient harm.”

Anne Bennett Swingle



Johns Hopkins Medicine

About DOME | Archive
© 2006 The Johns Hopkins University
and Johns Hopkins Health System