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:

1Patient's location/room number(s) 
2Did all personnel involved in line care for this patient use proper hand hygiene?[  ] Yes
[  ] No     If no, explain:
3Date of last CVC dressing change and skin condition at insertion site at that time 
4Was a 2 percent chlorhexidine/70 percent alcohol scrub followed by air dry used during last CVC dressing change?[  ] Yes
[  ] No     If no, explain:
5Was 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:
6Who 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
7Estimated number of CVC system entries for each 24-hour period for 72 hours prior to infection date 
8What are compliance rates for “scrubbing the hub” before accessing line on this unit? 
9Date of last IV administration set change(s)Lipid and/or blood products (q24h):
All other sets (q72-96h):
10Estimated hang time for parenteral fluid(s) over last 72 hours prior to infectionLipids (q24h):
All other fluids:
11Was central line removal discussed daily?[  ] Yes
[  ] No     If no, explain:
12Describe any mechanical problems with CVC prior to the infection date 
13Have there been any problems with the CVC or IV equipment or supplies?[  ] Yes     If yes, explain:
[  ] No
14Did the person who inserted the catheter have documented competency to insert?[  ] Yes
[  ] No     If no, explain:
15What is hand hygiene compliance like for all units the patient was in where patient had a CVC? 
16How did workload/unit activity affect insertion and care of the CVC? 
17Can each staff member involved in this patient's care verbalize correct strategies to prevent CLABSI?[  ] Yes
[  ] No     If no, explain:
18Are there any significant patient factors that may have contributed to this infection?[  ] Yes    If yes, explain:
[  ] No   
19After 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 January 2012
Internet Citation: 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. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/clabsitoolsap7.html