Infection-control case

Scenario summary: Patient A is recovering from abdominal surgery in a shared room. A staff member moved between Patient A and a patient with a draining wound without changing gloves. Patient A is on a medication that lowers immune function.

SOP I recorded for hand hygiene and PPE:

• Wash or sanitize hands before and after every patient contact.
• Don gloves and gown before touching a wound, doff them before leaving the bedside, then sanitize again.

Risk variables I identified:

• Patient immune status: lowered, which raises susceptibility.
• Staff behavior: gloves not changed between patients, which raises transmission risk.
• Environment: shared room with a draining-wound patient nearby, which raises exposure.

Chain trace for Patient A:

• Agent: wound bacteria from the neighboring patient.
• Reservoir: the draining wound.
• Portal of exit: wound drainage on the staff member's gloves.
• Mode of transmission: contaminated gloves carried to Patient A.
• Portal of entry: Patient A's surgical incision.
• Susceptible host: Patient A, immune-suppressed.

Weakest link: the mode of transmission, because the same gloves carried bacteria directly from one patient to another.

Recommended intervention: enforce glove change plus hand hygiene between every patient. This breaks the transmission link before bacteria can reach Patient A's incision.

Limitation: I assumed the neighboring wound is the source. If Patient A's own skin flora caused the infection, the glove-change rule would not be the highest-priority fix.