An interesting juxtaposition of news releases turned up today in an email called the “Critical Care SmartBrief.” One story described a significant reduction in infections at a Texas VA hospital, which had instituted a policy of swabbing the nose of every admitted patient looking for MRSA. The hospital’s program was part of a larger study published in the New England Journal of Medicine.
The other article described a problem of poor hygiene in VA hospitals in five states which has necessitated warnings to 13,000 veterans. Among other issues, a dentist was found to have used unsterile equipment. He also did not change dirty gloves between patients. So far, 61 patients have tested positive for hepatitis and 8 for HIV.
These two anecdotes raise some important issues. Although some health care quality gurus would have you believe that all errors are due to system failures, I believe that most are caused by humans. How could a 21st century dentist, presumably a graduate of an accredited school, use unsterile equipment and dirty gloves? You could ask, was he operating in a vacuum and should other personnel have noticed his poor technique? Can the VA ever improve its image? Is it possible to eradicate all mistakes in a complex environment like a hospital?
In the words of the late Roseanne Rosannadanna, “It’s always something!”