Healthcare Behaviors and Risky Business: First, Do No Harm

In an opinion piece entitled “Risky Business,” which was published in Infection Control and Hospital Epidemiology in 1990, Susan Beekmann, Barbara Fahey, Julie Gerberding, and I wrote about the subject of occupational risk for blood-borne pathogen transmission in the healthcare setting.1 In that piece, we presented a table suggesting a group of prevention strategies that we believed could help mitigate some of the risks associated with managing patients infected with hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and other blood-borne pathogens in healthcare settings (Table). In 1999, the Institute of Medicine of the National Academy of Sciences published an assessment of patient safety in U.S. healthcare institutions.2 The Institute of Medicine report was entitled “To Err Is Human.” This report underscored the frequency of adverse events in healthcare and emphasized the importance of getting healthcare workers to modify ingrained behaviors to improve patient safety and to mitigate risk in the healthcare setting.2 The first information about the acquired immunodeficiency syndrome (AIDS) was published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report on June 6, 1981.3 Because of the striking similarities between the epidemiology of this new syndrome and that of HBV, concern arose almost immediately about the risks for occupational and nosocomial transmission.4 As early as 1986, documented episodes of occupational infection were reported in the literature.5 Despite an awareness—as early as 1949—of the occupational hazards associated with handling blood from, and managing patients infected with, HBV,6 the healthcare profession had never seriously addressed issues related to workplace safety in a systematic way before the HIV epidemic. Interest in worker safety had just begun to develop concomitant with the marketing of the original HBV vaccine in the late 1970s, but this interest was truly galvanized by the HIV epidemic. The ensuing 25 years have seen a variety of interventions designed to facilitate both decreasing risks and “doing no harm” in the healthcare setting. In some respects, as a profession, we have come to understand these risks far better than one might have ever imagined in the early 1980s. That’s the good news. The bad news is that we continue to struggle on a daily basis with what must now be considered “routine” practice issues relating to the transmission of blood-borne pathogens in the healthcare setting. What must be considered simply “bad behaviors” continue to occur in our workplace on a far-toofrequent basis. As is so often the case in medicine, progress is incremental and not necessarily linear. This issue of Infection Control and Hospital Epidemiology contains no fewer than seven articles addressing various aspects of patient and healthcare worker safety relating directly to the presence of blood-borne pathogens in the healthcare environment. Unfortunately—from both the risky business and the first, do no harm perspectives— much of the news in this issue is not good. Four of these articles describe epidemics of blood-borne pathogen infections among patients receiving healthcare in four different TABLE* STRATEGIES TO PREVENT OCCUPATIONAL EXPOSURES AND INFECTIONS WITH BLOOD-BORNE PATHOGENS