Reduce infections with root-cause analysis: responding to infection-related sentinel events. (The Quality--Cost Connection).

Publication: Hospital Peer Review

Publication Date: 01-JUN-03

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COPYRIGHT 2003 A Thomson Healthcare Company

Infection control practitioners play a vital role in reducing nosocomial infections. Collecting and analyzing surveillance data can identify patterns of occurrence so that steps can be taken to eliminate or reduce the factors that contribute to nosocomial infections. The Joint Commission on Accreditation of Healthcare Organization's recent expansion of the sentinel event policy to include nosocomial infections could represent a change in what infection control practitioners view as their traditional role. In addition to discovering the root cause of undesirable infection patterns, practitioners now may be called upon to investigate an unexpected death or patient injury.

A knee-jerk response to a possible infection-related sentinel event would be to explain how difficult it is to establish a clear and concise relationship between a patient's infection and the adverse outcome in question. Often patients who develop nosocomial infections have a host of other medical problems and contributing factors. For example, sepsis from gram-positive pneumonia is a common cause of death among patients hospitalized with severe burns. Is it possible for practitioners to determine if the severely burned...

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