A Hospital-wide Outbreak of Serratia marcescens, and Ishikawa's "Fishbone" Analysis to Support Outbreak Control

Quality Management in Health Care
Luzia VetterMarco Rossi

Abstract

A nosocomial outbreak of Serratia marcescens in respiratory samples predominantly from patients in a surgical intensive care unit is reported. Most of these patients were cardiac surgical patients. Initially, a vigorous but inconclusive investigation was implemented on the basis of standardized (according the US Centers for Disease Control and Prevention) steps of outbreak investigation. Then, a systemic quality management approach with "fishbone" analysis was added. As a consequence, plausible causes for the outbreak were identified: (i) S marcescens was found on the transesophageal echocardiography probe used during cardiac surgery; and (ii) the quality of the surface disinfection was insufficient due to multiple reasons and was completely reengineered. In conclusion, in addition to the standardized steps of outbreak investigation, the complementary use of quality management tools such as the Ishikawa "fishbone" analysis is helpful for outbreak control. The complete reengineering of the disinfectant procurement and logistics is assumed to have been the most effective measure to control the described outbreak.

Citations

May 19, 2017·Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America·Hajime KanamoriDavid J Weber
Jul 24, 2018·Research in Gerontological Nursing·Nicole RuggianoMonica Scaccianoce
Aug 28, 2018·Ultrasound : Journal of the British Medical Ultrasound Society·David ScottAnnette Rankin
Jul 17, 2020·Frontiers in Microbiology·Roumayne L FerreiraMaria-Cristina da Silva Pranchevicius
Jun 6, 2018·Frontiers in Microbiology·Luisa Sandner-MirandaRosario Morales-Espinosa
Jul 7, 2017·Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America·Leah M SchuppenerNasia Safdar
Dec 28, 2021·AORN Journal·Karina de Souza HajarKazuko Uchikawa Graziano

❮ Previous
Next ❯

Methods Mentioned

BETA
electrophoresis
light microscopy
membrane filtration

Software Mentioned

Epicurve
Intercooled Stata

Related Concepts

Trending Feeds

COVID-19

Coronaviruses encompass a large family of viruses that cause the common cold as well as more serious diseases, such as the ongoing outbreak of coronavirus disease 2019 (COVID-19; formally known as 2019-nCoV). Coronaviruses can spread from animals to humans; symptoms include fever, cough, shortness of breath, and breathing difficulties; in more severe cases, infection can lead to death. This feed covers recent research on COVID-19.

Blastomycosis

Blastomycosis fungal infections spread through inhaling Blastomyces dermatitidis spores. Discover the latest research on blastomycosis fungal infections here.

Nuclear Pore Complex in ALS/FTD

Alterations in nucleocytoplasmic transport, controlled by the nuclear pore complex, may be involved in the pathomechanism underlying multiple neurodegenerative diseases including Amyotrophic Lateral Sclerosis and Frontotemporal Dementia. Here is the latest research on the nuclear pore complex in ALS and FTD.

Applications of Molecular Barcoding

The concept of molecular barcoding is that each original DNA or RNA molecule is attached to a unique sequence barcode. Sequence reads having different barcodes represent different original molecules, while sequence reads having the same barcode are results of PCR duplication from one original molecule. Discover the latest research on molecular barcoding here.

Chronic Fatigue Syndrome

Chronic fatigue syndrome is a disease characterized by unexplained disabling fatigue; the pathology of which is incompletely understood. Discover the latest research on chronic fatigue syndrome here.

Evolution of Pluripotency

Pluripotency refers to the ability of a cell to develop into three primary germ cell layers of the embryo. This feed focuses on the mechanisms that underlie the evolution of pluripotency. Here is the latest research.

Position Effect Variegation

Position Effect Variagation occurs when a gene is inactivated due to its positioning near heterochromatic regions within a chromosome. Discover the latest research on Position Effect Variagation here.

STING Receptor Agonists

Stimulator of IFN genes (STING) are a group of transmembrane proteins that are involved in the induction of type I interferon that is important in the innate immune response. The stimulation of STING has been an active area of research in the treatment of cancer and infectious diseases. Here is the latest research on STING receptor agonists.

Microbicide

Microbicides are products that can be applied to vaginal or rectal mucosal surfaces with the goal of preventing, or at least significantly reducing, the transmission of sexually transmitted infections. Here is the latest research on microbicides.

Related Papers

Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
Juan M Muñoz, Alejandro E Macías
Infection Control and Hospital Epidemiology : the Official Journal of the Society of Hospital Epidemiologists of America
G DorseyD R Bangsberg
© 2022 Meta ULC. All rights reserved