infection prevention
By Barbara DeBaun , MSN , RN , CIC
How Can We Connect the Dots Between a Missed Hand Hygiene Opportunity and Subsequent Patient Harm ?
It ’ s been 175 years since Ignaz Semmelweis proposed the practice of washing hands with chlorinated lime solution as a strategy to prevent transmission of potentially lethal bacteria . The Centers for Disease Control and Prevention ( CDC ) issued its first guideline for handwashing in 1985 and the APIC guidelines followed 10 years later . Guidelines have been updated over the years with new knowledge and alternative approaches to hand hygiene such as alcohol-based hand sanitizer . The Joint
Even though the healthcare provider ’ s contaminated hands are a possible source of the CLABSI , the time delay between the breach and onset of infection is significant , therefore the dots don ’ t get connected .”
Commission issued the first set of National Patient Safety Goals in 2002 and , not surprising , one of the goals was to reduce the risk of healthcare associated infections by complying with either the current CDC hand hygiene guidelines or the current World Health Organization ( WHO ) hand hygiene guidelines .
Infection preventionists are leading efforts worldwide to impact hand hygiene compliance in healthcare facilities . We oversee the hand hygiene observation programs , recruit observers , train them , analyze their findings , display data , and report findings to multiple committees and stakeholders . We conduct activities using black light technology to ‘ make the invisible germs visible ’ and do our best to find ways for fun and interactive activities . We find ways to provide reward and recognition when observing a good example of hand hygiene with every ounce of creativity . Some of us have established code phrases such as “ Gel-in , gel out ,” “ Can I give you a hand ?” “ Dr . Hand is on the phone ,” or even “ Touchdown ” for an observed hand hygiene and “ Fumble ” when observing a missed opportunity . These code phrases can be quite effective , but they might be brushed off or dismissed as a subtle suggestion , rather than a hard stop .
So , let ’ s shift gears for a moment . Think about all the safety checks we have in place to minimize the chance of a patient receiving the wrong type of blood or the wrong medication . It is estimated that in the United States alone , between 7,000 and 9,000 people die every year because of a medication error . Approximately 20 people in the U . S . die every year after receiving an incompatible transfusion of blood . In most circumstances , administration of incompatible blood results in an immediate and
dramatically obvious error . The nurse who hung the blood will see the impact of the error quickly and connect the dots between the wrong blood and the patient harm . If a nurse administers a medication to a patient with a severe allergy or grabs the wrong concentration or heparin and delivers a much higher dose than indicated , the error will be obvious . The dots between the human error and the harm to the patient get connected .
But what happens if a healthcare provider fails to perform hand hygiene and touches a patient ’ s central line with contaminated hands ? Might the patient develop a central line-associated bloodstream infection ( CLABSI )? Very possibly . But the difference is the healthcare-associated infection will not be obvious immediately , such as with a blood transfusion reaction or a severe systemic allergic reaction . Even though the healthcare provider ’ s contaminated hands are a possible source of the CLABSI , the time delay between the breach and onset of infection is significant , therefore the dots don ’ t get connected .
So , how can we change the conversation and get better at not only seeing a hand hygiene failure as a human error , but to create a powerful peer-to-peer support system where staff welcome and appreciate a direct reminder to do the right thing for patient safety ?
You might want to try some role playing that goes something like this . Approach a nurse and ask the following :
➊ If I saw you about to hang the wrong blood on your patient , would you want me to stop you ?
➋ If I saw you about to give penicillin to a patient with a severe penicillin allergy , would you want me to stop you ?
See how the nurse responds , but likely s / he will say “ Yes ” or “ Absolutely ” without missing a beat .
Next , ask the nurse :
➊ If I saw you about to touch a patient without washing your hands , would you want me to stop you ?
The response might be a little different . Some will respond with an immediate “ Yes ,” and others might hesitate a bit because this particular question may feel more personal or judgmental . The important outcome of this exercise is to create a dialogue and have the conversation that promotes ‘ connecting the dots ’ between a human error and patient harm . Ultimately , we want our healthcare providers to view healthcare associated infections as preventable harms that are just as significant as those that result from medication or blood administration errors . Go get those dots connected !
Barbara DeBaun , MSN , RN , CIC , is improvement advisor for Cynosure Health .