 investigation of infection control breaches this section lists some key resources that provide useful background materials and advice to assist with the investigation and response to infection control breaches as well as some examples of publications in which infection control breach investigators described their specific findings and experiences 1 schaefer mk perkins km link gelles r kallen aj patel pr perz jf outbreaks and infection control breaches in health care settings considerations for patient notification am j infect control 2020 jun 48 6 718 724 available at https www ncbi nlm nih gov pmc articles pmc7894041 this paper provides a useful framework for patient notification considerations including a description of triggers for performing a notification when investigating an infection control breach as well as examples of commonly encountered scenarios 2 patel pr srinivasan a perz jf developing a broader approach to management of infection control breaches in healthcare settings am j infect control 2008 36 685 90 available at https www ajicjournal org article s0196 6553 08 00683 4 fulltext this paper introduced a number of useful concepts and suggested approaches for investigating infection control breaches many of which were revisited and expanded upon by schaefer et al reference 1 from this section 3 centers for medicare and medicaid services cms infection control breaches which warrant referral to public health authorities available at https www cms gov medicare providerenrollment and certification surveycertificationgeninfo downloads survey and cert letter14 36 pdf beginning in 2014 cms required the reporting of infection control breaches discovered during accrediting or certification survey visits to public health agencies 4 braun bi chitavi so perkins km perz jf et al referrals of infection control breaches to public health authorities ambulatory care settings experience 2017 available at https www ncbi nlm nih gov pmc articles pmc7876613 the authors characterized and summarized the ipc breaches that were identified by joint commission surveyors during the ambulatory health care and office based surgery accreditation process and reported to state health departments in 2017 5 cdc injection safety patient notification toolkit available at https www cdc gov injectionsafety pntoolkit index html this toolkit provides step wise guidance to assist public health agencies and healthcare facilities with conducting a patient notification following identification of an infection control breach the toolkit is intended to be used after the decision has been made to notify patients and offers resources and template materials such as sample notification letters as well as some essential tips and strategies 6 schoonover h haydon k incident command structure using a daily management system and the centers for disease control and preventions patient notification toolkit drives effective response to an infection control breach j healthc risk manag 2018 oct 38 2 19 26 available at https onlinelibrary wiley com doi abs 10 1002 jhrm 21323 the authors describe how an incident command structure information management system and cdc patient notification toolkit were used to drive an effective response to an infection control breach resulting in 92% of affected patients completing the recommended testing 7 arnold s melville sk morehead b vaughan g moorman a crist mb notes from the field hepatitis c transmission from inappropriate reuse of saline flush syringes for multiple patients in an acute care general hospital texas 2015 mmwr morb mortal wkly rep 2017 66 258 260 available at https www cdc gov mmwr volumes 66 wr mm6609a4 htm this report provides an example of an infection control breach investigation which uncovered hepatitis c virus transmission 8 rasmussen sa goodman ra editors 2018 the cdc field epidemiology manual available at https www cdc gov eis field epi manual index html this reference does not address infection control breaches specifically but provides a comprehensive resource for responding to outbreaks with many principles that can also be applied to infection control breach investigations particularly relevant chapters to healthcare infection control breach investigations include chapters 3 conducting a field investigation 12 communicating during an outbreak or public health investigation and 18 healthcare settings selected infection control resources and references this section provides general resources for understanding the basic principles of infection control as well as some detailed resources that are relevant to some of the more commonly reported infection control breaches 1 centers for disease control and prevention cdc infection control available at https www cdc gov infectioncontrol index html this webpage is the base directory for cdc infection control resources including links to resources for standard and transmission based precautions infection control guidelines reference 2 in this section training and education resources and tools for specific healthcare setting types 2 centers for disease control and prevention cdc infection control guidelines guidance library available at https www cdc gov infectioncontrol guidelines index html this webpage contains links to a variety of cdc infection control guidelines and documents including those developed under the auspices of the healthcare infection control practices advisory committee hicpac 3 association for professionals in infection control and epidemiology apic the apic text available at https apic org resources apic text a comprehensive infection control resource organized by chapter subscription required 4 centers for disease control and prevention cdc essential elements of a reprocessing program for flexible endoscopes ─ recommendaoons of the hicpac available at https www cdc gov hicpac recommendations flexible endoscope reprocessing html because many breaches involve medical device reprocessing techniques this resource can assist public health agencies in related investigations and can be a useful document to share with and help educate facilities 5 centers for disease control and prevention cdc infection prevention during blood glucose monitoring and insulin administration available at https www cdc gov injectionsafety bloodglucose monitoring html this cdc resource provides essential background when investigating infection control breaches associated with blood glucose monitoring or other forms of point of care testing involving capillary blood samples or insulin pens and other medication cartridges 6 centers for disease control and prevention cdc injection safety available at https www cdc gov injectionsafety index html a website landing page for information about safe injection practices safe injection practices are part of standard precautions and are aimed at maintaining basic levels of patient safety and healthcare provider protections 7 dolan sa arias km felizardo g barnes s kraska s et al apic position paper safe injection infusion and medication vial practices in health care am j infect control 2016 jul 1 44 7 750 7 available at https apic org resource tinymcefilemanager position statements 2016apicsippositionpap er pdf position paper from the association for professionals in infection control and epidemiology describing risks and outbreaks associated with unsafe injection practices and associated recommendations investigation of a drug diversion event broadly speaking when prescription medicines are obtained or used illegally it is called drug diversion healthcare providers who steal prescription medicines such as opioids for their own use put patients at risk for harms this can include exposure to infectious diseases for example when a provider commits diversion by tampering with or otherwise misusing injection supplies medications or other equipment these items might become contaminated with hepatitis b or c virus hiv or bacteria drug diversion investigations involve assessments and actions that are akin to infection control breach investigations but with many special considerations the resources below provide guidance and useful background for investigation of healthcare drug diversion events 1 schaefer mk perz jf outbreaks of infections associated with drug diversion by us health care personnel mayo clin proc 2014 89 7 878 87 available at https www ncbi nlm nih gov pmc articles pmc4669560 this review article summarizes a variety of drug diversion related outbreak investigations and includes a table describing key investigation steps 2 centers for disease control and prevention cdc injection safety drug diversion available at https www cdc gov injectionsafety drugdiversion index html this website provides information on drug diversion including outbreaks associated with drug diversion resources for clinicians and additional resources 3 council of state and territorial epidemiologists 2019 healthcare associated infections hai drug diversion planning and response toolkit for state and local health departments available at https www cste org page drug diversion toolkit this toolkit provides information on best practices when responding to a drug diversion and provides resources informed by past drug diversion investigations 4 brummond pw chen df churchill ww clark js dillon kr et al ashp guidelines on preventing diversion of controlled substances am j health syst pharm 2017 mar 1 74 5 325 348 available at https www ashp org media assets policyguidelines docs guidelines preventing diversion of controlled substances ashx this guidance document is a framework from the american society of health system pharmacists describing controlled substance diversion prevention programs and provides useful context for public health partners and others charged with investigating a drug diversion report 