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Infection preventionist sparks product recall

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Whaley receives patient safety award for uncovering B. cepacia outbreak

Imagine spending several months trying to find the pathogen responsible for a cluster of infections among critically ill, hospitalized patients. For infection prevention specialists with the right skills and resources, solving this mystery is a daunting but not impossible task.

B. cepacia is a bacterium found in soil and water that can be resistant to antibiotics and can cause life-threatening infection in high-risk, medically complex children, such as children with cystic fibrosis and immunocompromising conditions.

When Texas Children's experienced a small outbreak of B. cepacia infection in February 2016, Quality and Safety Director Elaine Whaley, RN, immediately sprang into action to identify the cause of the outbreak. Her extensive experience in infection prevention and control and her professional networking skills helped her locate fellow infection prevention specialist Angela Rupp of Lurie Children’s Hospital in Chicago who encountered a similar outbreak at her hospital.

When the two clusters were confirmed to be identical, the investigations were combined. Together, Whaley and Rupp identified the product directly responsible for the sudden outbreak of infection at both hospitals – liquid docusate, a medication used to treat constipation. After thorough analysis, they found that the docusate product at each hospital came from the same manufacturer. After reporting these findings to the Centers for Disease Control, the Food and Drug Administration was called into the investigation and a national recall of the product was expedited, protecting patients at Texas Children's and pediatric hospitals across the nation from a serious pathogen.

As a result of their collaborative work and commitment to promoting a culture of safe patient care, Whaley and Rupp were recognized with the Heroes of Infection Prevention Award during a special ceremony in Portland by the Association for Professionals in Infection Control and Epidemiology (APIC).

“It is a great honor to have one of our own be nationally recognized for this heroic award in patient safety,” said Trudy Leidich, assistant vice president of Quality and Safety at Texas Children’s Hospital. “We are grateful to Elaine and our Infection Control team for identifying the direct source of contamination in order to keep our patients safe and free from preventable harm.”