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The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has issued a Sentinel Event Alert on Creutzfeldt-Jakob Disease (CJD). The Joint Commission has received reports that patients at two hospitals may have been exposed to CJD through instruments used during brain surgeries.
The alert includes an exploration of the incident at Exempla Saint Joseph Hospital in Denver, which encountered exposure to CJD in 2000 (For more information on an incident at Tulane University Hospital and Clinic in New Orleans, see Same-Day Surgery, April 2001, p. 37.)
"Although CJD is rare — only one in 1 million people worldwide have been diagnosed with CJD — and iatrogenic transmission of CJD by exposure to central nervous system tissue or spinal fluid of a diseased person is even rarer, these new incidents signal the need for renewed awareness of preventive measures in health care organizations in regards to infection control," the Joint Commission said in a released statement in which it referred providers to the standards in The Comprehensive Accreditation Manual for Hospitals, IC.1-IC.6.2.
"This is particularly important since regular sterilization techniques are not yet proven to be effective against the CJD organism," the Joint Commission adds.
To view the Sentinel Event Alert, go to www.jcaho.org/edu_ pub/sealert/sea20.html. (For information on CJD draft guidelines from the Centers for Disease Control and Prevention, see SDS, August 2001, p. 91.)