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[ ] Yes [ ] No If no, explain: Were all elements complied with when CVC inserted?[ ] Yes [ ] No If no, explain: 1Patients location/room number(s)2Did all personnel involved in line care for this patient use proper hand hygiene?[ ] Yes [ ] No If no, explain:3Date of last CVC dressing change and skin condition at insertion site at that time4Was a 2 percent chlorhexidine/70 percent alcohol scrub followed by air dry used during last CVC dressing change?[ ] Yes [ ] No If no, explain:5Was a 70 percent alcohol or 2 percent chlorhexidine/70 percent alcohol followed by air dry used prior to accessing the CVC hub/port? (Use facilitys protocol.)[ ] Yes [ ] No If no, explain:6Who accessed the CVC system 48-72 hours before infection date? (Check all that apply)[ ] Floor nurse [ ] Nurse from other unit [ ] Attending MD [ ] Resident/Fellow [ ] Anesthesia [ ] Radiology [ ] Other7Estimated number of CVC system entries for each 24-hour period for 72 hours prior to infection date8What are compliance rates for scrubbing the hub before accessing line on this unit?9Date of last IV administration set change(s)Lipid and/or blood products (q24h): All other sets (q72-96h):10Estimated hang time for parenteral fluid(s) over last 72 hours prior to infectionLipids (q24h): All other fluids:11Was central line removal discussed daily?[ ] Yes [ ] No If no, explain:12Describe any mechanical problems with CVC prior to the infection date13Have there been any problems with the CVC or IV equipment or supplies?[ ] Yes If yes, explain: [ ] No14Did the person who inserted the catheter have documented competency to insert?[ ] Yes [ ] No If no, explain:15What is hand hygiene compliance like for all units the patient was in where patient had a CVC?16How did workload/unit activity affect insertion and care of the CVC?17Can each staff member involved in this patients care verbalize correct strategies to prevent CLABSI?[ ] Yes [ ] No If no, explain:18Are there any significant patient factors that may have contributed to this infection?[ ] Yes If yes, explain: [ ] No 19After your assessment, do you believe this infection was potentially preventable?[ ] Yes Explain: [ ] No Explain: If defects are identified, use the HYPERLINK "http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc"Learning from Defects Tool in the CUSP Toolkit to prevent future defect(s).     @z{ 0 J ] _ o p ȹ{o{o{o`o`o`{h87hcCJOJQJaJhcCJOJQJaJh87h? eCJOJQJaJh87hUhCJOJQJaJhUhh@5CJOJQJaJhUhh=*5CJOJQJaJh=*h@CJOJQJaJh87hR,CJaJh87h)gCJOJQJaJh87hR,CJOJQJaJh]hO? hchW z{Mkd$$IflF *X  t06    44 lapyt87 $Ifgd9gd9gdcWRRII $Ifgd9gd9kd$$IflF *X  t06    44 lapyt87 $Ifgd)g xoo $Ifgd9kdd$$Ifl0V*F t0644 lapyt87   0 o xoooof $Ifgdc $Ifgd9kd$$Ifl0V*F t0644 lapyt87 xsg^^ $Ifgd9 $$Ifa$gd87gd9kd$$Ifl0V*F t0644 lapyt87 ' - ? 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