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Problem
You are the Administrator of a children's hospital. In this hospital, you have had a rise in central line infections (due to a central venous catheter). Through a series of Quality Improvement initiatives (which you will learn about in HSMP 3600: Quality Improvement), you determine improper cleaning of the hub site (the port next to the skin where the catheter is inserted). You normally had nursing cleaning the hub with ethanol, but found that the best practice according to the literature is to clean it with ChloraPrep. So you take ethanol out of the treatment carts, and the infections improve. However, it is soon found that ethanol is required per the policies and procedures to clean other items in the patient's room. ChloraPrep works on these other items just as well as ethanol, but the P&P specifies ethanol. So you return ethanol to the treatment carts, and after some time your infection rates go back up.
Task
What happened? Why did infection rates go back up? What can you do about your policy and procedures?
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