Vascular Catheter-Associated Infection
Cause Mapping Example:
It has been estimated that 80,000 vascular catheter-related infections occur each year, resulting in up to 28,000 deaths. The average cost of each infection is $45,000, making this a multi-billion dollar problem. Additionally, Mediare and Medicaid will no longer reduce health facilities for costs associated with these infections.
Obviously the number of these incidents need to be reduced. But how? We will use a root cause analysis to find out. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.
A vascular-catheter related infection, typically a bloodstream infection, is caused when a catheter is inserted and bacteria follow along for the ride. The bacteria can come from several sources, including natural skin flora, poor aseptic technique, and contamination of the catheter itself. The causes of these contamination sources include a catheter left in too long without entry site disinfection, pathogens on the hands of medical personnel, and incidental contact of the catheter with a contaminated surface. The bacteria can be helped along by surface irregularities or surfaces less resistant to pathogen adherence.
Techniques for reducing bloodstream infections (solutions) are shown with the cause they control. For example, using proper aseptic technique, changing catheters at a fixed interval and using catheters made of materials more resistant to adherence by pathogens can reduce the number of bloodstream infections at a facility.
The full root cause analysis investigation showing the causes and associated solutions to reduce bloodstream infections can be found on the downloadable PDF.
Click on "Download PDF" above to download a PDF showing the Root Cause Analysis Investigation.
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