Abstract
The University of Utah Newborn Intensive Care Unit (UUNICU) has seen a recent increase in rate of Central Line Associated Bloodstream Infection (CLABSI) after an extended period of 965 days with no CLABSI’s. Unfortunately, in the last three years, infection rate has been on average 2.6 CLABSI per year. The goal of this study was to identify potential contributing factors leading to this substantial increase. To conceptualize these factors, we focused on the emergence of safety conflicts during the intravenous medication administration process. A safety conflict was defined as an interference between two separate pathways designed to protect the integrity of patient care (a ‘safety pathway’). A total of 30 structured health care worker observations of the intravenous medication administration process were conducted. Data analysis shows a notable increase in safety conflict frequency, and necessary LCs as the number of medications per administration event increases. Conversely, the average duration of a single vs. two medication administration events does not significantly increase, which indicates substantial batching of tasks. This batching increases the likelihood of safety conflicts, negatively affecting patient safety.
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