I've worked in the healthcare field for many years, and have written protocols and supporting applications to measure practise standards around central line procedures (both in and out of ICU environments), and I can say quite definitively that while CLI infections as a result of procedural mistakes happen, they are not the low hanging fruit you think they are.
If I had to nominate three low hanging fruits with respect to medical errors, they would be:
- Hand washing. Colleagues of mine have researched and written extensively about this issue; study after study bears out the numbers people are quoting here. I'll source some references and reply with them.
- Positive patient ID. The high flying stories about operating on the wrong patient, or on the wrong limb are one thing, but much more sinister is the issue of mislabeled blood work, specialist reports that are delayed due to mismatched paperwork, and medication mis-administration (more on this later). The degree to which healthcare professionals operate in an environment of mislabeled, misattributed, and simply missing documentation is astounding.
- Medication Administration. A close colleague of mine has made a career around studying the practice of chemotherapy administration and the reduction of errors therein. The feedback she gets when presenting to practitioners is both very encouraging (they, of course, genuinely want to improve their practice), and also disheartening (very simple changes to process have simply never occurred to many front-line staff. They're consistently amazed that the idea of process improvement is even a thing).
If you've ever been in the unfortunate position of having to see chemo being (properly) administered, you get to see firsthand how rigorous process controls are supposed to work. Every bag that gets hung is triple checked via different calculation paths, every patient's identity is re-confirmed every time (even patients that have been on the ward for months), and every interaction with infusion pumps is double checked by at least two nurses after every action. It's a great thing to witness; it's just sad that it isn't the norm everywhere in healthcare.
CL procedure auditing: The work I did was as an oversight tool internal to UHN -- we implemented a handheld tool to allow roaming nurses to audit practice adherence for many high infection risk procedures, including those related to central line insertion and maintenance. Our work was based on the guidelines set by http://www.saferhealthcarenow.ca/EN/Interventions/CLI/Pages/... . I left the group while the intervention was in progress, so I'm not aware of any specific publications.
Positive patient ID: The PPID work that I've been exposed to was targeted at in-hospital evaluations of various vendor systems; I'm not aware of it having been published externally. If you're interested I can follow up with members of the team who worked on this to see if anything public came out of it.
If I had to nominate three low hanging fruits with respect to medical errors, they would be:
- Hand washing. Colleagues of mine have researched and written extensively about this issue; study after study bears out the numbers people are quoting here. I'll source some references and reply with them.
- Positive patient ID. The high flying stories about operating on the wrong patient, or on the wrong limb are one thing, but much more sinister is the issue of mislabeled blood work, specialist reports that are delayed due to mismatched paperwork, and medication mis-administration (more on this later). The degree to which healthcare professionals operate in an environment of mislabeled, misattributed, and simply missing documentation is astounding.
- Medication Administration. A close colleague of mine has made a career around studying the practice of chemotherapy administration and the reduction of errors therein. The feedback she gets when presenting to practitioners is both very encouraging (they, of course, genuinely want to improve their practice), and also disheartening (very simple changes to process have simply never occurred to many front-line staff. They're consistently amazed that the idea of process improvement is even a thing).
If you've ever been in the unfortunate position of having to see chemo being (properly) administered, you get to see firsthand how rigorous process controls are supposed to work. Every bag that gets hung is triple checked via different calculation paths, every patient's identity is re-confirmed every time (even patients that have been on the ward for months), and every interaction with infusion pumps is double checked by at least two nurses after every action. It's a great thing to witness; it's just sad that it isn't the norm everywhere in healthcare.