Central Venous Catheter-Associated Laboratory-Confirmed Blood Stream Infection Event Report Template for Defect Analysis

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Patient:	MR No:	Admit Date:
Diagnosis:	Infection Date:	Criteria:                  Organism:

CVC Insertion Info

Date:	Type:
Location:	Who Inserted:
Insertion Site: Date CVC Removed:	Was insertion bundle used? [  ] Yes   [  ] No If no, explain: Were all elements complied with when CVC inserted?[  ] Yes  [  ] No If no, explain:

1	Patient's location/room number(s)
2	Did all personnel involved in line care for this patient use proper hand hygiene?	[  ] Yes [  ] No     If no, explain:
3	Date of last CVC dressing change and skin condition at insertion site at that time
4	Was a 2 percent chlorhexidine/70 percent alcohol scrub followed by air dry used during last CVC dressing change?	[  ] Yes [  ] No     If no, explain:
5	Was a 70 percent alcohol or 2 percent chlorhexidine/70 percent alcohol followed by air dry used prior to accessing the CVC hub/port? (Use facility's protocol.)	[  ] Yes [  ] No     If no, explain:
6	Who accessed the CVC system 48-72 hours before infection date? (Check all that apply)	[  ] Floor nurse   [ ] Nurse from other unit  [  ] Attending MD  [  ] Resident/Fellow   [  ] Anesthesia   [  ] Radiology   [  ] Other
7	Estimated number of CVC system entries for each 24-hour period for 72 hours prior to infection date
8	What are compliance rates for “scrubbing the hub” before accessing line on this unit?
9	Date of last IV administration set change(s)	Lipid and/or blood products (q24h): All other sets (q72-96h):
10	Estimated hang time for parenteral fluid(s) over last 72 hours prior to infection	Lipids (q24h): All other fluids:
11	Was central line removal discussed daily?	[  ] Yes [  ] No     If no, explain:
12	Describe any mechanical problems with CVC prior to the infection date
13	Have there been any problems with the CVC or IV equipment or supplies?	[  ] Yes     If yes, explain: [  ] No
14	Did the person who inserted the catheter have documented competency to insert?	[  ] Yes [  ] No     If no, explain:
15	What is hand hygiene compliance like for all units the patient was in where patient had a CVC?
16	How did workload/unit activity affect insertion and care of the CVC?
17	Can each staff member involved in this patient's care verbalize correct strategies to prevent CLABSI?	[  ] Yes [  ] No     If no, explain:
18	Are there any significant patient factors that may have contributed to this infection?	[  ] Yes    If yes, explain: [  ] No
19	After your assessment, do you believe this infection was potentially preventable?	[  ] Yes    Explain: [  ] No     Explain:

If defects are identified, use the Learning from Defects Tool in the CUSP Toolkit to prevent future defect(s).

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