The $70K Mistake: A Multidisciplinary Response to a Prion Disease Near-Miss

Session Description: Infection prevention programs rarely handle prion disease cases, but even one oversight can have severe consequences. This presentation discusses a case where a surgical patient with unexplained neurological symptoms was suspected to have prion disease as a differential diagnosis. However, this concern was not communicated to the operating room (OR) staff or Infection Prevention (IP) team before a scheduled brain biopsy.
The issue was only discovered when a scrub technician overheard a discussion and alerted the team. Although IP acted quickly to reduce risk, the surgery proceeded with standard instruments. The patient later tested positive for Creutzfeldt-Jakob disease (CJD), resulting in the destruction of over $70,000 in surgical equipment.

This incident led to the formation of a multidisciplinary taskforce including OR, Lab, IP, and Neurology/Neurosurgery teams. They developed a proactive protocol involving lab alerts to IP when 14-3-3 protein or Real-Time Quaking-Induced Conversion (RT-QuIC) tests are ordered, real-time case tracking, and clear guidelines on instrument use.

The case highlights the critical need for cross-disciplinary communication and the risks of assumptions in clinical care. It also raised questions still under debate, such as the safety of using power drills in suspected prion cases—a topic with limited published guidance.

Nicole Bland

Infection Preventionist, WVU Medicine United Hospital Center

My name is Nicole Bland, MPH, CIC, CHES. I am an infection preventionist at WVU Medicine United Hospital Center in Bridgeport, WV. I earned a Bachelor of Science in Community Health Education at Fairmont State University and a Master of Public Health with a graduate certificate in Health Education and Promotion from Benedictine University. I am Certified in Infection Control (CIC) through the Certification Board of Infection Control and Epidemiology (CBIC) and hold the Certified Health Education Specialist (CHES) credential from the National Commission for Health Education Credentialing (NCHEC). Additionally, I have been an active volunteer with the Creutzfeldt-Jakob Disease Foundation since 2007 and a current member of the national Board of Directors since April 2025.

Kathy Nigh

Infection Preventionist, WVU Medicine

WVU Medicine 35years IP 15 years Certified in Infection Prevention and long term care Outside work Garden, Bird watch trail walking Love the ocean and beach vacations Proud German Shepard mom

Nicole Henry

Infection Preventionist, NYC H+H - Bellevue

Miss Henry is a dedicated Infection Preventionist with NYC Health + Hospitals, bringing extensive experience in public health and infectious disease prevention. She previously served as a Public Health Advisor at the Centers for Disease Control and Prevention, contributing to COVID-19 response efforts and other infectious disease initiatives. As a published author and dynamic speaker, she has presented at both national and international infection prevention conferences, sharing expertise on innovative strategies to reduce healthcare-associated infections and improve patient safety. As an active member of the APIC Greater New York Chapter and the National APIC Health Equity Committee, Miss Henry is passionate about advancing equitable infection prevention practices and positively contributing to the infection prevention community. When not immersed in the world of epidemiology and healthcare quality improvement, she enjoys exploring diverse cuisines and traveling to experience global cultures. Miss Henry strives to make infection prevention both impactful and engaging.