After reading this why does this continue to be an issue?

10 Chapter 1 Hospitals Through the Ages FAILURE TO FOLLOW HAND HYGIENE GUIDELINES Sheri was a healthy 30-year-old female until she suddenly experienced neck pain with a numbness radiating down her left arm. She was diagnosed with cervical rib outlet syndrome and agreed to a surgical procedure by Dr. Botchit for removal of her first cervical rib. Sheri was admitted to a postsurgical care unit at a major teaching hospital. Upon entering her assigned four-bed room, she and her husband Bill observed a bloody suction bottle hanging from the wall at the head of her assigned bed. The bed rails were rusting with dried bloody body fluids from a previous patient. They were uneasy about having a surgical procedure performed but they decided the physician's skills were more important than an unclean room. Bill commented, "Well, at least the sheets appear clean." Elda, the first patient on the left upon entering the room greeted Sheri and Bill. She said, " The room isn't very clean is it? Could you watch out for the nurses?" She then smiled as she removed Tylenol from her bedside table. She took a few and said, "I don't want my doctor to cancel my surgery, so I have to lower my temperature before the nurses retake my temperature. I think I have an infection. I have waited so long to get my surgery scheduled. I am just so worried my surgery will be canceled." The morning following surgery, a third-year resident entered the room with three first-year residents and beginning with Elda, examined each of four postsurgical patients. Elda was a postsurgical amputee, who was later diagnosed with a staph infection. Sheri was the fourth patient to be examined in the room. Even though each of the patient's wounds had been examined and dressings changed, the physicians failed to change their surgical gloves between patients. Following examination of Sheri, they proceeded to remove their gloves and tossed them in Sheri's bedside wastebasket. They then washed their hands at the only sink in the room, which was by Sheri's bedside. Sheri's temperature began to rise. Bill asked if a wound culture had been taken. Carol, the nurse manager after checking Sheri's chart said, said, "No culture was ordered." He asked, "Can you please have a culture ordered?"The nurse replied that she would call Dr. Green to see if he would order a blood culture." Bill asked, "Who is Dr. Green?" Carol replied, "Dr. Green is covering for Dr. Botchit while he is on vacation. Dr. Botchit left on a family skiing trip the day after surgery to Aspen, Colorado." Bill learned the following day that the blood tests came back positive for a staph infection and learned that no antibiotics had been prescribed by Dr. Green. Bill became increasingly concerned about the lack of care and went back to the nursing station to describe his concern about the lack of treatment for Sheri. Carol suggested that he call Dr. Green. Bill placed a call to Dr. Green and relayed his concern about his wife's deteriorating health. Dr. Green returning Bill's call said, "I hear you are unhappy with my care. I am merely providing coverage for Dr. Botchit. I have my own patients to be concerned with and treat." Bill replied, "Well if you are covering for another physician you need to address my wife's infection." Dr. Green replied, "I am doing a favor for Dr. Botchit by covering his patients as well as mine. I will get to the hospital when I can!" Upon returning to his wife's bedside, Sheri looked up at him and said, "The priest was here and administered last rites to me."Looking at his mother-in-law, who was trying to be strong, holding back the tears, Bill devotedly said, "I will fix this." He called Dr. Field, who he knew was a physician educator at the medical center, and explained his concerns. Dr. Field said, "I can help. I will get a team of infectious disease specialists to Sheri's bedside. They are the best in the city, probably the world. But please do not use my name in any dispute that you may have with Dr. Botchit or Dr. Green." Sheri survived but the staph infection had taken its toll on her immune system. Sheri and Bill never thought much about it at the time, but in hindsight, Elda's infection was most likely the contributing factor to the staph infections that eventually affected the other three patients in the room. History repeated itself. Despite being adopted by the hospital, the CDC hand-washing guidelines, which could have helped prevent the infection, were not followed,. This reality check illustrates how the failure to follow established protocols in the prevention of infections can have disastrous consequences for patients. Progress in the delivery of patient care can move forward only as long as complacency does not stymie progress. This case also provides an important lesson for patients who treat themselves, masking their physical symptoms, as in this case where the patient took Tylenol to hide her fever, an indicator that the patient may have an active infection. Staff should be alert to patients who self-treat and confiscate all home and store bought medications upon admission to the hospital. The lessons here also apply to family members, who must not honor patient requests for medications. This reality check serves as a reminder that his- both caregivers and patients. The