"No one could have anticipated this outcome," says senior hospital epidemiologist Trish Perl, M.D., an associate professor of medicine and pathology at The Johns Hopkins University School of Medicine. "But, our experience underscores how advances in technology designed to improve health care may also have hidden risks to patients that can only be identified by paying close attention to what happens after the technology is put into practice."

In a case study reported in the latest edition of the journal Infection Control and Hospital Epidemiology online Jan. 6, a team of Hopkins patient safety experts describe how the introduction of a catheter valve newly marketed to the hospital in April 2004 coincided with a spike in potentially deadly bloodstream infections picked up by patients in the hospital's pediatric intensive care unit, or PICU, and other intensive care units.

Once the increased rate was confirmed, Hopkins experts launched an investigation that identified an intravenous catheter valve as the likely source of infection. No one at Hopkins died from the infections. Hopkins stopped using the valve and alerted the United States Food and Drug Administration, which approves use of medical devices, and the U.S. Centers for Disease Control and Prevention, which monitors infections in hospitals, the report noted.

"While new technology in health care is frequently beneficial or easier to use, it takes time and use to determine whether these devices are in fact safe," says Lisa Maragakis, M.D., the hospital epidemiologist who led the investigation. "It may be harder to clean and disinfect some new technologies, which can lead to p
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Contact: David March
dmarch1@jhmi.edu
410-955-1534
Johns Hopkins Medical Institutions
9-Jan-2006