Body fluid and microbiological contamination can remain on, or within, bed and stretcher mattresses and mattress covers after cleaning. This puts subsequent patients and even staff at risk of exposure to infectious materials. Mattress and mattress cover contamination may go unrecognized and unreported, unless a patient experiences body fluid oozing from the mattress surface. To increase knowledge about the prevalence of patient safety events related to mattress and mattress cover contamination, Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and the U.S. Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) databases for reports of body fluid and microbiological contamination of bed and stretcher mattresses and covers submitted between January 1, 2005, and March 31, 2018 (PA-PSRS), and between January 1, 2008, and March 31, 2018 (MAUDE). Analysts identified 14 events reported through PA-PSRS of patient exposure to a previous patient's blood or urine when it oozed out of their support surface. In addition, analysts identified five reports in the MAUDE database of patient bloodborne pathogen exposure to a previous patient's blood when it seeped out of the support surface. Review of PA-PSRS and MAUDE event reports provides insight about how these events occur and adds depth to FDA's 2017 guidance and 2013 Safety Communication regarding the problem of body fluid ingress in hospital mattresses and covers. To reduce the risk of such contamination, a joint initiative with the infection prevention and control, environmental services, and clinical/biomedical engineering departments to address inadequate mattress cover reprocessing and deficient inspection of mattresses and mattress covers may be needed.
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)