Patient Safety Alert
Resultant Harm to the Patient
Five critically-ill patients with hospital-associated Mucormycosis, specifically Rhizopus, all subsequently expired.
Actions to Mitigate Risk at Your Hospital
- Skin assessment should be performed on a regular basis on all immobile, at-risk patients, which include patients with diabetes, prematurity/low birth weight, metabolic acidosis, immunocompromised, and/or renal failure. Consider steam-sterilized linens for at-risk patients.
- Hospital linens should be laundered and covered in a manner that reduces environmental exposure to dust and dirt during transport.
- Consider site visits to linen service facilities. Obtain and monitor quality assurance records.
- Review the location of the linen loading area, especially during construction.
- Monitor linen storage sites during Environment of Care rounds to ensure linen is clean and dust free.
- Infection Prevention
- Patient Safety
- Risk Management
- Cause Analysis Staff
- Organizational Leaders
- Nursing and Clinical Leaders
- Supply Chain Services
- Environmental Services
Cutaneous Mucormycosis, in these cases Rhizopus, is an invasive, rapidly spreading fungal infection which usually occurs in often terminal patients whose suppressed immune system cannot fight off the infection.
Upon recognition, the Office of Public Health and the Centers for Disease Control (CDC) was contacted to assist in the investigation. The investigation revealed this fungus is common in dirt and soil and hospital linens were identified as the likely source of the infection, with contamination occurring possibly during transport. According to the CDC this is the first and only incident of linens transmitting Rhizopus.
Contact Kate Conrad, Vice President, (913) 981-4118 or Barbara Weis, Project Specialist, (913) 981-4117.