Complete the root cause analysis ONLY AFTER YOU HAVE DONE THE FOLLOWING:

1. Gather your facility's data for bloodstream infections and dialysis events from January 1, 2018 - June 30, 2018.

2. Meet with all staff who would have firsthand knowledge of the incidents or processes that led to each event.

3. Determine the human and other factors most directly associated with these infections.

If you would like to keep this in your facility's records or include it in your monthly QAPI meeting, please print before clicking on the Submit button. This can be done by right clicking the screen and select the PRINT option.

All questions should be answered to the best of your knowledge. If any questions are left blank, you will be contacted by the Network to redo the survey. Thank you!

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* 2. Complete the below information.

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* 3. How many bloodstream infections/dialysis events occurred between January 1, 2018 through June 30, 2018?

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* 5. How many staff members (including yourself) did you meet with to discuss the bloodstream infections/dialysis events that occurred between January 1, 2018 through June 30, 2018 for this survey?

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* 7. Were the infections for each month discussed in your monthly QAPI meeting with the medical director and staff? Choose N/A if there were no infections that month.

  YES NO N/A
January
February
March
April
May
June

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* 8. JANUARY: What human or other factors contributed to the infection(s) this month? What actions were taken as a result?  (If there were no infections this month, put N/A in the comment box.)

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* 9. FEBRUARY: What human or other factors contributed to the infection(s) this month? What actions were taken as a result?  (If there were no infections this month, put N/A in the comment box.)

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* 10. MARCH: What human or other factors contributed to the infection(s) this month? What actions were taken as a result?  (If there were no infections this month, put N/A in the comment box.)

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* 11. APRIL: What human or other factors contributed to the infection(s) this month? What actions were taken as a result?  (If there were no infections this month, put N/A in the comment box.)

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* 12. MAY: What human or other factors contributed to the infection(s) this month? What actions were taken as a result?  (If there were no infections this month, put N/A in the comment box.)

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* 13. JUNE: What human or other factors contributed to the infection(s) this month? What actions were taken as a result?  (If there were no infections this month, put N/A in the comment box.)

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* 14. What type of safeguards are CURRENTLY in place and ACTIVELY USED  in your facility to prevent infections? (Select all that apply.)

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* 15. What would you change (if you could) within your facility to provide a better experience of care for the patients and/or staff?

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* 16. What would you like to see patients DO DIFFERENTLY to reduce infections?

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* 17. What would you like to see patients KEEP DOING to reduce infections?

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* 18. What would you like to see staff DO DIFFERENTLY to reduce infections?

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* 19. What would you like to see staff KEEP DOING to reduce infections?

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* 20. Why do you think this facility has a high BSI rate?

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