Infection control today reported that a recent outbreak of a rare bacteria was tied to a lapse in infection control procedures. There was an outbreak of Tsukamurella blood stream infections, which is caused by Gram-positive bacteria and rarely effects humans. The outbreak was linked to the improper handling of saline at a West Virginia outpatient oncology clinic.
These investigations also suggested that saline flush syringes were the likely source of infection
After implementing a new method the occurrence of the infections ceased. The CDC has developed guidelines and checklists to help similar facilities. Here is a link to the CDC guidelines for Outpatient Settings.