From Exposure Event to Action Plan at APIC 2026: Providence Develops Playbook for Managing Large-Scale Patient Notifications

Managing a large-scale patient exposure event can quickly become one of the most complex challenges faced by infection prevention programs. While most health care organizations maintain exposure response plans, these plans often focus on clinical and regulatory requirements and may not fully address operational, legal, communication, and patient follow-up challenges that arise when thousands of patients are potentially affected.

At the Association for Professionals in Infection Prevention and Epidemiology Annual Conference and Exposition held from June 15 to 17, 2026, in Nashville, Tennessee, Keenan Williamson, MPH, CIC, senior infection prevention manager, and Larissa Taylor, RN, at Providence Health & Services, presented a poster describing a framework designed to help health care systems better prepare for and manage these high-consequence events. The poster, "Gaps to Guidance: A Healthcare System's Guide to Managing Large-scale Patient Exposures," outlines lessons learned from 2 major bloodborne pathogen (BBP) exposure investigations that affected more than 3,000 patients across 3 hospitals.

According to Williamson and colleagues, infection prevention and control (IPC) departments routinely manage communicable disease exposures, including bloodborne pathogens. However, large-scale exposure events often reveal gaps in preparedness.

"Although exposure management plans are required of IPC departments, many insufficiently coordinate strategic communications, assess legal implications, and provide guidance for follow-up patient notifications and testing during large-scale events," the authors noted.

The project was born out of real-world experience. Between Spring 2024 and Summer 2025, Providence Health & Services managed 2 significant patient exposure incidents. The first involved lapses in safe injection practices during anesthesia administration, requiring notification of more than 2,000 patients. The second involved failures in endoscopy reprocessing, including nonadherence with manufacturer instructions for use and inadequate high-level disinfection practices, resulting in notification to an additional 1,000 patients.

Following these events, investigators conducted a gap analysis and postevent evaluation to identify strengths, weaknesses, and opportunities for improvement. The lessons learned were incorporated into a comprehensive bloodborne pathogen exposure playbook designed to guide future responses.