Pennsylvania Patient Safety Authority Provides Prevention Strategies to Reduce CLABSI


Data submitted by Pennsylvania hospitals in 2010 pinpoints timelines for prevention strategies for reducing and/or eliminating central line-associated bloodstream infections (CLABSI), according to information published in the September 2011 Pennsylvania Patient Safety Advisory.

Central venous catheters (CVC) are used as one form of access to a patient's veins for medications and other fluids. While CVCs are necessary, their use puts patients at risk for CLABSI. Infection can occur within the first five days of insertion, known as the insertion phase, or after the first five days, which is known as the maintenance phase.

The Pennsylvania Patient Safety Authority studied CLABSI data reported by Pennsylvania healthcare facilities in calendar year 2010. The data showed that in over 70 percent of the CLABSI cases, the infections occurred more than five days after the CVC was placed in the patient. Infections from bacteria occurring after five days may signify weaknesses in the maintenance phase of monitoring CVCs.

"Authority analysis shows that facilities may want to consider focusing more resources on the maintenance phase of CVCs to help reduce CLABSIs," says James Davis, BSN, RN, CCRN, CIC, analyst for the Pennsylvania Patient Safety Authority. "Infection preventionists, who detailed their descriptions of the CLABSI events by providing CVC insertion dates, helped the Authority determine that most cases of CLABSI in Pennsylvania healthcare facilities developed during the maintenance phase.

"Pennsylvania hospitals should take another look at how their resources for preventing CLABSIs are being used and perhaps reallocate them based upon this new information," Davis adds. "Of course, continuing best practices and compliance monitoring during the insertion phase should also remain in the prevention plan."

To help Pennsylvania hospitals assess their overall CLABSI prevention programs, the Authority provides a CLABSI prevention toolkit, available on its website at; click on "Educational Tools." CLABSI consumer tips are also available for patients and caregivers.

For more information on the methodology used for the data analysis and to read the complete Advisory article go to "Central-Line-Associated Bloodstream Infection: Comprehensive, Data-Driven Prevention" on the Authority's website under Patient Safety Advisories September 2011.

The Authority's 2011 September Advisory also contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights include:

- A Review of Medication Errors in Ambulatory Surgery Facilities (ASFs): Motivated by the lack of medical literature that quantitatively addresses medication errors occurring in ambulatory surgical settings, analysts reviewed medication errors reported to the Pennsylvania Patient Safety Authority and determined the most common error types, patient populations and medications involved. Pennsylvania ambulatory surgery facilities (ASFs) submitted 502 medication error reports to the Authority from June 28, 2004, through December 31, 2010. The most common types of medication errors reported by ASFs included drug omission, wrong drug and monitoring error/documented allergy. More than one-third of intravenous wrong-drug events involved high-alert medications. Strategies to prevent wrong-drug errors, especially for high-alert medications, are provided in this Advisory article "Ambulatory Surgery Facilities: A Comprehensive Review of Medication Error Reports in Pennsylvania."

- Wrong-Site Surgery Update: The two-year wrong-site surgery project continues with the second lowest quarterly total to date. Two near-miss reports submitted to the Authority show the importance of preventative measures. The first highlights the value of a time-out and the second shows how problems can be resolved rationally. This article examines the possible impact of each previously proposed best practice principle for preventing wrong-site surgery. A wrong-site surgery toolkit is available as an additional resource for healthcare facilities to prevent wrong-site surgeries. The toolkit and complete Advisory article "Quarterly Update: What Might Be the Impact of Using Evidence-Based Best Practices for Preventing Wrong-Site Surgery?" are available on the Authority's website. Consumer tips for preventing wrong-site surgery are also available.

Fostering Safety-Conscious Healthcare Providers: A Leadership Initiative: This article focuses on the importance of employee empowerment in promoting patient safety within a healthcare facility. Highlighted in this article are examples of how empowered employees in Pennsylvania healthcare facilities were able to prevent an adverse event because they voiced their concern and the concern was addressed. Pennsylvania healthcare facilities continually struggle with maintaining a "culture of safety." The Authority encourages healthcare workers to share this article with leaders, executives and colleagues to show the benefits of promoting a working environment that is safety-conscious.

For the complete 2011 September Pennsylvania Patient Safety Advisory, go to

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