Appendix 7. Central Venous Catheter-Associated Laboratory-Confirmed Blood Stream Infection Event Report Template for Defect Analysis

Tools for Reducing Central Line-Associated Blood Stream Infections
These tools will help your unit implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI). When used with the CUSP (Comprehensive Unit-based Safety Program) Toolkit, these tools dramatically reduced CLABSI rates in more than 1,000 hospitals across the country.
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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Page last reviewed October 2014
Internet Citation: Appendix 7. Central Venous Catheter-Associated Laboratory-Confirmed Blood Stream Infection Event Report Template for Defect Analysis. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/clabsitoolsap7.html