Quality Improvement in Vascular Access

Establishes the organizational framework for continuous quality improvement in vascular access services, including the adoption of validated QI methodologies, audit and feedback mechanisms, adverse event surveillance, medication safety integration, and the maintenance of a Just Culture environment.

policies•Jan 2026•Quality Improvement

Quality Improvement in Vascular Access Policy

1. Policy Statement

It is the policy of this organization that vascular access services shall be subject to a continuous, systematic quality improvement (QI) program that drives patient safety and clinical excellence through ongoing surveillance, data analysis, and proactive intervention.12 The QI program shall operate within a Just Culture framework that balances individual accountability with system-level improvement, utilizes validated improvement methodologies, and integrates medication safety and technology analytics into its surveillance activities.345

2. Purpose

This policy exists to:

  • Establish quality improvement as a mandatory, continuous, and interprofessional activity—not a static document or annual exercise—that is embedded in the daily operations of vascular access services.6
  • Require the maintenance of a Just Culture that encourages clinician reporting of errors, near-misses, and system vulnerabilities without fear of retribution, focusing on process improvement rather than individual blame.345
  • Mandate the adoption of validated QI methodologies (PDCA, Lean Six Sigma, RCA, HFMEA) for the systematic identification, analysis, and resolution of vascular access quality and safety issues.27
  • Define the requirements for audit and feedback mechanisms that translate surveillance data into actionable, real-time feedback for frontline clinicians.89
  • Establish the organization’s surveillance and adverse event monitoring requirements for all vascular access devices.1011
  • Integrate medication safety and infusion technology analytics into the vascular access QI program.1213

3. Scope

This policy applies to:

  • All members of the Vascular Access Governance Committee, the Vascular Access Specialist Team, the Quality and Patient Safety Department, Infection Prevention, Pharmacy, Clinical Education, and all other departments and individuals who contribute to vascular access quality and safety activities.
  • All vascular access devices and infusion therapy activities within the organization.
  • All clinical settings within the organization.
  • All adverse events, near-misses, and quality indicators related to vascular access.

4. Policy Requirements

4.1 Just Culture Framework

4.1.1 The organization shall maintain a Just Culture for all vascular access quality and safety activities.34514 Under this framework:

  • System Focus. The primary focus of quality improvement shall be on identifying and correcting system-level failures, process deficiencies, and environmental factors that contribute to adverse events, rather than assigning individual blame for errors that arise from system vulnerabilities.31
  • Error Reporting. All clinicians shall be expected and encouraged to report vascular access errors, near-misses, and unsafe conditions through the organization’s electronic safety reporting system without fear of punitive action.151617 Reports shall be treated as confidential quality improvement data to the extent permitted by law.
  • Accountability Balance. While the organization emphasizes system improvement, individual accountability is maintained for reckless behavior, willful violations of safety protocols, and impaired practice.14 The organization shall use a validated algorithm (e.g., the Just Culture Algorithm™) to distinguish between human error (console), at-risk behavior (coach), and reckless behavior (discipline).5

4.1.2 Non-Retaliation. No clinician shall face adverse employment action, harassment, or professional retaliation for reporting a vascular access safety concern, error, or near-miss in good faith.314 Retaliation against a reporter is itself a policy violation subject to disciplinary action.

4.2 Quality Improvement Methodologies

4.2.1 The VAGC and Quality Department shall employ the following validated improvement frameworks as appropriate to the nature and scope of the quality issue:182

PDCA (Plan-Do-Check-Act). The standard iterative four-step cycle for continuous process improvement.27 PDCA shall be the default methodology for routine improvement initiatives, including protocol revisions, workflow optimizations, and compliance improvement projects.67

Lean Six Sigma. Applied for initiatives focused on eliminating waste and reducing variability in clinical workflows (e.g., standardizing the steps of a dressing change procedure, reducing turnaround time for VAST consultations, minimizing supply waste in insertion kits).1920 Lean methodology has demonstrated effectiveness in reducing healthcare-associated infections and improving catheter-care efficiency.1920

Root Cause Analysis (RCA). A mandatory, systematic, retrospective analysis conducted following any sentinel event, serious safety event, or cluster of adverse events related to vascular access.2122 RCA shall identify the contributing factors at the individual, team, system, and environmental levels, and shall produce a corrective action plan with defined responsible parties and completion timelines.2122

Healthcare Failure Mode and Effect Analysis (HFMEA). A proactive, prospective analysis methodology used to identify where a vascular access process might fail before the failure occurs.2324 HFMEA shall be conducted when: a new vascular access procedure is being introduced, a significant process change is being implemented, or a high-risk process is being redesigned.2324

4.2.2 Methodology Selection. The VAGC shall determine the appropriate methodology for each quality initiative based on the nature of the issue (reactive vs. proactive), the severity of the risk, and the scope of the process involved.182 The rationale for methodology selection shall be documented in the QI project charter.18

4.3 Audit and Feedback Mechanisms

4.3.1 Rationale-Driven Audits. Every vascular access audit shall have a clearly defined purpose linked to a specific quality indicator or patient safety objective.89 Audits shall not be conducted without a documented “why” that connects the audit to a measurable outcome.2526 For example, an audit of needleless connector disinfection compliance shall be directly linked to CABSI rate monitoring.27

4.3.2 Audit Types and Frequency.2526

  • Concurrent observational audits of vascular access insertion technique, site assessment, dressing changes, and hand hygiene shall be conducted by VAST members and Infection Prevention during clinical rounding, at minimum monthly.2829
  • Retrospective chart audits of vascular access documentation completeness, line necessity reviews, and complication reporting shall be conducted by the Quality Department at minimum quarterly.30
  • Focused audits addressing specific identified concerns (e.g., a spike in phlebitis rates on a specific unit) shall be initiated within five (5) business days of the concern being identified and shall continue until the issue is resolved.18

4.3.3 Real-Time Feedback. Audit findings shall not be held in reserve until a scheduled report.831 Findings must be translated into timely verbal and written feedback for frontline staff to guide immediate practice correction.313233 The feedback loop shall include: individual coaching for the clinician observed (at the time of the observation when possible),31 unit-level aggregate data shared with the Charge Nurse and Unit Manager within one (1) week of the audit,32 and organizational aggregate data reported to the VAGC at each quarterly meeting.9

4.3.4 Standardized Definitions. Data definitions, inclusion criteria, and measurement methods shall be standardized across all units and facilities within the organization to ensure valid “apples-to-apples” comparisons.1011 The Quality Department shall maintain a Vascular Access Data Dictionary that defines each metric, its numerator, denominator, exclusion criteria, and data source.3435

4.4 Surveillance and Adverse Event Monitoring

4.4.1 The organization shall conduct aggressive, continuous surveillance of all vascular access devices.3611 The following metrics shall be tracked, trended, and reported:

Infection Rates. Catheter-Associated Bloodstream Infection (CABSI) rates per 1,000 central line days, calculated and benchmarked using NHSN methodology and definitions.113738 CABSI surveillance data shall be reviewed by Infection Prevention and the VAGC monthly.3936

Premature Device Removal. Analysis of all vascular access devices removed before the completion of prescribed therapy, including the reason for premature removal (complication, patient request, device malfunction, accidental dislodgment).1028 Root causes of premature removal shall be analyzed quarterly to identify preventable causes.4041

Unnecessary Placements. Audits of CVAD utilization to ensure patients are not receiving invasive central lines when peripheral access would be clinically sufficient.42 The CVAD appropriateness rate shall be tracked and reported quarterly.42

Mechanical Complications. Incidence rates for catheter occlusion, venous thromboembolism, infiltration, extravasation, phlebitis (graded by severity), catheter migration, catheter fracture or embolization, and pneumothorax.102829

4.4.2 Surveillance Reporting. The Quality Department shall produce a Vascular Access Quality Dashboard that is updated at minimum monthly and is accessible to all VAGC members, unit managers, and organizational leadership.2829 The dashboard shall include trend data with statistical process control (SPC) charts to distinguish between common-cause and special-cause variation.34354344

4.4.3 Trigger Events. The following events shall trigger an immediate investigation (within 48 hours): any CABSI event, any catheter-related death or serious harm, any cluster of two or more similar complications on the same unit within a defined period, and any event requiring external regulatory reporting.39453646474849

4.5 Medication Safety and Technology Analytics

4.5.1 Close Call (Near-Miss) Reporting. The organization’s safety reporting system shall be configured to capture vascular access-related “close calls”—incidents that were intercepted before reaching the patient.1750 Close call data shall be analyzed with the same rigor as actual events, as they represent the organization’s most valuable proactive safety intelligence.15165152 Barriers to near-miss reporting, including fear of blame, perceived futility, and time constraints, shall be systematically addressed through Just Culture education and system redesign.1516

4.5.2 Smart Pump Analytics. The VAGC and Pharmacy shall collaborate to regularly review data from smart infusion pumps, including: DERS alert and override rates by drug, unit, and clinician role; frequency and nature of programming errors; and patterns of “workaround” behavior that bypasses safety features (e.g., infusing outside of the drug library).1253135455 Findings shall be reported to the Medication Safety Committee and used to refine drug library parameters and inform targeted staff education.1253135455

4.5.3 Barcode Medication Administration (BCMA) Analytics. The VAGC shall collaborate with Pharmacy and HIT to review BCMA compliance data for medications administered through vascular access devices.5657 BCMA bypass rates and wrong-route scan events shall be tracked and addressed through system redesign and staff education.5859

4.5.4 Technology-Driven Improvement. The VAGC shall advocate for and support the implementation of clinical decision support (CDS) tools within the EHR that improve vascular access safety, including automated line necessity reminders, dressing change due alerts, and hard stops for high-risk infusion orders that require verification of appropriate access type.601256

5. Compliance

5.1 Monitoring. Compliance with this policy shall be monitored through review of the Vascular Access Quality Dashboard metrics and trends, tracking of RCA completion rates and corrective action implementation within defined timelines, audit and feedback cycle completion rates, safety event reporting volume (with the expectation that higher reporting volume indicates a healthier safety culture),345 and annual Just Culture assessment (staff survey measuring perception of reporting safety).514

5.2 Key Performance Indicators.3435

  • CABSI rate per 1,000 central line days (benchmarked against NHSN national data).114344
  • Premature device removal rate with identified preventable cause rate.1028
  • CVAD appropriateness rate.42
  • Safety event report volume (year-over-year trend).1516
  • Close call reporting rate (target: year-over-year increase).1750
  • RCA corrective action completion rate within defined timelines (target: 100%).2122
  • Smart pump override rate (target: year-over-year reduction).5313

5.3 Enforcement. Failure to report a known adverse event or sentinel event is a serious policy violation.316 Failure of leadership to conduct a required RCA, implement corrective actions, or maintain surveillance reporting shall be escalated to the Chief Nursing Officer and Chief Medical Officer.146

6. Exceptions

6.1 During periods of declared institutional emergency, surveillance and audit activities may be temporarily reduced to essential indicators only (CABSI, sentinel events). Full surveillance shall be restored within thirty (30) days of the emergency resolution.61

6.2 No exception shall be granted for the Just Culture non-retaliation provisions or the mandatory reporting of sentinel events.35

  • SOP-VA-080: Vascular Access Root Cause Analysis Procedure
  • SOP-VA-081: HFMEA Procedure for Vascular Access Processes
  • SOP-VA-082: Vascular Access Concurrent Observational Audit Procedure
  • SOP-VA-083: Smart Pump Override Review Procedure
  • POL-004: Strategic Planning and Implementation of Vascular Access Services
  • POL-005: Service Delivery Models and Operational Scope
  • POL-006: Interprofessional Safety and Care Transitions
  • Vascular Access Quality Dashboard (maintained by Quality Department)
  • Vascular Access Data Dictionary
  • Organizational Safety Event Reporting Policy
  • Organizational Just Culture Policy
  • NHSN CABSI Surveillance Protocol
  • Joint Commission National Patient Safety Goals

References

8. Revision History

VersionDateAuthor(s)Description of Change
1.02026-02-01D. Woo, M. Stern, I.M. WrightInitial policy creation and approval
1.12026-02-23D. Woo, M. Stern, I.M. WrightAdded comprehensive academic references
———Scheduled review date: 2027-02-01

  1. Firstenberg MS, Stawicki SP. Introductory chapter: the decades long quest continues toward better, safer healthcare systems. In: Firstenberg MS, Stawicki SP, eds. Vignettes in Patient Safety. IntechOpen; 2017. ↩︎ ↩︎

  2. Ratner S, Pignone M. Quality improvement principles and practice. Prim Care Clin Off Pract. 2019;46(4):505-514. doi:10.1016/j.pop.2019.07.008 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  3. Aveling EL, Parker M, Dixon-Woods M. What is the role of individual accountability in patient safety? A multi-site ethnographic study. Sociol Health Illn. 2016;38(2):216-232. doi:10.1111/1467-9566.12370 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  4. Ghaferi AA, Dimick JB. Understanding failure to rescue and improving safety culture. Ann Surg. 2015;261(5):839-840. doi:10.1097/SLA.0000000000001135 ↩︎ ↩︎ ↩︎ ↩︎

  5. Billings DM, Kowalski K, Armstrong G. QSEN safety competency: the key ingredient is just culture. J Contin Educ Nurs. 2019;50(10):444-447. doi:10.3928/00220124-20190917-05 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  6. O’Donoghue SC, DiLibero J, Altman M. Leading sustainable quality improvement. Nurs Manage. 2021;52(2):42-50. doi:10.1097/01.Numa.0000724940.43792.86 ↩︎ ↩︎ ↩︎

  7. Knudsen SV, Laursen HVB, Johnsen SP, Bartels PD, Ehlers LH, Mainz J. Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Serv Res. 2019;19(1):683. doi:10.1186/s12913-019-4482-6 ↩︎ ↩︎ ↩︎

  8. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;2012(6):CD000259. doi:10.1002/14651858.CD000259.pub3 ↩︎ ↩︎ ↩︎

  9. Ivers NM, Grimshaw JM, Jamtvedt G, et al. Growing literature, stagnant science? Systematic review, meta-regression and cumulative analysis of audit and feedback interventions in health care. J Gen Intern Med. 2014;29(11):1534-1541. doi:10.1007/s11606-014-2913-y ↩︎ ↩︎ ↩︎

  10. Schults J, Kleidon T, Chopra V, et al. International recommendations for a vascular access minimum dataset: a Delphi consensus-building study. BMJ Qual Saf. 2021;30(9):722-730. doi:10.1136/bmjqs-2020-011274 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  11. Centers for Disease Control and Prevention. Bloodstream infection event (central line-associated bloodstream infection and non-central line-associated bloodstream infection). National Healthcare Safety Network (NHSN) Patient Safety Component Manual. 2023. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  12. Lehr J, Vitoux RR, Zavotsky KE, Pontieri-Lewis V, Colineri L. Achieving outcomes with innovative smart pump technology: partnership, planning, and quality improvement. J Nurs Care Qual. 2019;34(1):9-15. doi:10.1097/NCQ.0000000000000326 ↩︎ ↩︎ ↩︎ ↩︎

  13. Institute for Safe Medication Practices. Guidelines for optimizing safe implementation and use of smart infusion pumps. 2020. https://www.ismp.org/guidelines/smart-pumps ↩︎ ↩︎ ↩︎ ↩︎

  14. Mathews SC, Demski R, Pronovost PJ. Redefining accountability in quality and safety at academic medical centers. Qual Manage Health Care. 2016;25(4):244-247. doi:10.1097/QMH.0000000000000107 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  15. Dirik HF, Samur M, Seren Intepeler S, Hewison A. Nurses’ identification and reporting of medication errors. J Clin Nurs. 2019;28(5-6):931-938. doi:10.1111/jocn.14716 ↩︎ ↩︎ ↩︎ ↩︎

  16. Rutledge DN, Retrosi T, Ostrowski G. Barriers to medication error reporting among hospital nurses. J Clin Nurs. 2018;27(9-10):1941-1949. doi:10.1111/jocn.14335 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  17. Speroni KG, Fisher J, Dennis M, Daniel M. What causes near-misses and how are they mitigated? Nursing. 2013;43(4):19-24. doi:10.1097/01.NURSE.0000427995.92553.ef ↩︎ ↩︎ ↩︎

  18. Barlow M, Dickie R, Morse C, Bonney D, Simon R. Documentation framework for healthcare simulation quality improvement activities. Adv Simul (Lond). 2017;2(1):19. doi:10.1186/s41077-017-0053-2 ↩︎ ↩︎ ↩︎ ↩︎

  19. Steere L, Rousseau M, Durland L. Lean Six Sigma for intravenous therapy optimization: a hospital use of lean thinking to improve occlusion management. JAVA. 2018;23(1):42-50. doi:10.1016/j.java.2018.01.002 ↩︎ ↩︎

  20. Sartini M, Patrone C, Spagnolo AM, et al. The management of healthcare-related infections through lean methodology: systematic review and meta-analysis of observational studies. J Prev Med Hyg. 2022;63(3):E464-E475. doi:10.15167/2421-4248/jpmh2022.63.3.2661 ↩︎ ↩︎

  21. Li X, He M, Wang H. Application of failure mode and effect analysis in managing catheter-related blood stream infection in intensive care unit. Medicine. 2017;96(51):e9339. doi:10.1097/MD.0000000000009339 ↩︎ ↩︎ ↩︎

  22. Franklin BD, Panesar SS, Vincent C, Donaldson LJ. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. BMJ Qual Saf. 2014;23(9):765-772. doi:10.1136/bmjqs-2013-002572 ↩︎ ↩︎ ↩︎

  23. Faiella G, Parand A, Franklin BD, et al. Expanding healthcare failure mode and effect analysis: a composite proactive risk analysis approach. Reliab Eng Syst Saf. 2018;169:117-126. doi:10.1016/j.ress.2017.08.003 ↩︎ ↩︎

  24. Arenas Jiménez MD, Ferre G, Álvarez-Ude F. Strategies to increase patient safety in haemodialysis: application of the modal analysis system of errors and effects (FEMA system). Nefrologia. 2017;37(6):608-621. doi:10.1016/j.nefroe.2017.11.011 ↩︎ ↩︎

  25. Ullman AJ, Ray-Barruel G, Rickard CM, Cooke M. Clinical audits to improve critical care: Part 1: prepare and collect data. Aust Crit Care. 2018;31(2):101-105. doi:10.1016/j.aucc.2017.04.003 ↩︎ ↩︎

  26. Ray-Barruel G, Ullman AJ, Rickard CM, Cooke M. Clinical audits to improve critical care: Part 2: analyse, benchmark and feedback. Aust Crit Care. 2018;31(2):106-109. doi:10.1016/j.aucc.2017.04.002 ↩︎ ↩︎

  27. Shettigar S, Somasekhara Aradhya A, Ramappa S, Reddy V, Venkatagiri P. Reducing healthcare-associated infections by improving compliance to aseptic non-touch technique in intravenous line maintenance: a quality improvement approach. BMJ Open Qual. 2021;10(Suppl 1):e001394. doi:10.1136/bmjoq-2021-001394 ↩︎

  28. Platt V, Osenkarski S. Improving vascular access outcomes and enhancing practice. J Infus Nurs. 2018;41(6):375-382. doi:10.1097/NAN.0000000000000304 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

  29. Morrell E. Reducing risks and improving vascular access outcomes. J Infus Nurs. 2020;43(4):222-228. doi:10.1097/nan.0000000000000377 ↩︎ ↩︎ ↩︎

  30. Yagnik L, Graves A, Thong K. Plastic in patient study: prospective audit of adherence to peripheral intravenous cannula monitoring and documentation guidelines. Am J Infect Control. 2017;45(1):34-38. doi:10.1016/j.ajic.2016.09.008 ↩︎

  31. Morrison T, Raffaele J, Brennaman L. Impact of personalized report cards on nurses managing central lines. Am J Infect Control. 2017;45(1):24-28. doi:10.1016/j.ajic.2016.09.020 ↩︎ ↩︎ ↩︎

  32. Christina V, Baldwin K, Biron A, Emed J, Lepage K. Factors influencing the effectiveness of audit and feedback: nurses’ perceptions. J Nurs Manage. 2016;24(8):1080-1087. doi:10.1111/jonm.12409 ↩︎ ↩︎

  33. De Bie AJR, Mestrom E, Compagner W, et al. Intelligent checklists improve checklist compliance in the intensive care unit: a prospective before-and-after mixed-method study. Br J Anaesth. 2021;126(2):404-414. doi:10.1016/j.bja.2020.09.044 ↩︎

  34. National Quality Forum. The ABCs of measurement. https://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx ↩︎ ↩︎ ↩︎

  35. Institute for Healthcare Improvement. Measures. https://www.ihi.org/Topics/Improvement/improvement-methods/Pages/Measures.aspx ↩︎ ↩︎ ↩︎

  36. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(5):553-569. doi:10.1017/ice.2022.87 ↩︎ ↩︎ ↩︎

  37. Hallam C, Jackson T, Rajgopal A, Russell B. Establishing catheter-related bloodstream infection surveillance to drive improvement. J Infect Prevent. 2018;19(4):160-166. doi:10.1177/1757177418767759 ↩︎

  38. Larsen EN, Gavin N, Marsh N, Rickard CM, Runnegar N, Webster J. A systematic review of central-line-associated bloodstream infection (CLABSI) diagnostic reliability and error. Infect Control Hosp Epidemiol. 2019;40(10):1100-1106. doi:10.1017/ice.2019.205 ↩︎

  39. Campbell AJ, Chen YP, Gough L, et al. Lessons learned from a hospital-wide review of blood stream infections for paediatric central line-associated blood stream infection prevention. J Paediatr Child Health. 2019;55(6):690-694. doi:10.1111/jpc.14276 ↩︎ ↩︎

  40. Boyar V, Galiczewski C. Reducing peripheral intravenous catheter extravasation in neonates: a quality improvement project. J Wound Ostomy Cont Nurs. 2021;48(1):31-38. doi:10.1097/WON.0000000000000728 ↩︎

  41. Garrett A, Drake SA, Holcomb JB. Effects of a systematic quality improvement process to decrease complications in trauma patients with prehospital peripheral intravenous access. J Trauma Nurs. 2017;24(4):236-241. doi:10.1097/jtn.0000000000000297 ↩︎

  42. Xiong Z, Chen H. Interventions to reduce unnecessary central venous catheter use to prevent central-line-associated bloodstream infections in adults: a systematic review. Infect Control Hosp Epidemiol. 2018;39(12):1442-1448. doi:10.1017/ice.2018.250 ↩︎ ↩︎ ↩︎

  43. Yu KC, Ye G, Edwards JR, et al. Hospital-onset bacteremia and fungemia: an evaluation of predictors and feasibility of benchmarking comparing two risk-adjusted models among 267 hospitals. Infect Control Hosp Epidemiol. 2022;43(10):1317-1325. doi:10.1017/ice.2022.211 ↩︎ ↩︎

  44. Dantes RB, Abbo LM, Anderson D, et al. Hospital epidemiologists’ and infection preventionists’ opinions regarding hospital-onset bacteremia and fungemia as a potential healthcare-associated infection metric. Infect Control Hosp Epidemiol. 2019;40(5):536-540. doi:10.1017/ice.2019.40 ↩︎ ↩︎

  45. Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR, Shepperd S. Interventions to improve professional adherence to guidelines for prevention of device-related infections. Cochrane Database Syst Rev. 2013;2013(3):CD006559. doi:10.1002/14651858.CD006559.pub2 ↩︎

  46. Owings A, Graves J, Johnson S, Gilliam C, Gipson M, Hakim H. Leadership line care rounds: application of the engage, educate, execute, and evaluate improvement model for the prevention of central line-associated bloodstream infections in children with cancer. Am J Infect Control. 2018;46(2):229-231. doi:10.1016/j.ajic.2017.08.032 ↩︎

  47. Arrieta J, Orrego C, Macchiavello D, et al. ‘Adiós bacteriemias’: a multi-country quality improvement collaborative project to reduce the incidence of CLABSI in Latin American ICUs. Int J Qual Health Care. 2019;31(9):704-711. doi:10.1093/intqhc/mzz051 ↩︎

  48. Balla KC, Rao SPN, Arul C, et al. Decreasing central line-associated bloodstream infections through quality improvement initiative. Indian Pediatr. 2018;55(9):753-756. doi:10.1007/s13312-018-1374-5 ↩︎

  49. Han J, Wan J, Cheng Y, et al. A hospital-wide reduction in central line-associated bloodstream infections through systematic quality improvement initiative and multidisciplinary teamwork. Am J Infect Control. 2019;47(11):1358-1364. doi:10.1016/j.ajic.2019.05.008 ↩︎

  50. Urich B. Near misses and close calls: what they are and why you should report them. Nephrol Nurs J. 2015;42(3):205, 208. ↩︎ ↩︎

  51. Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports. Patient Saf. 2020;2(1):31-47. doi:10.33940/data/2020.3.3 ↩︎

  52. Kavanagh C. Medication governance: preventing errors and promoting patient safety. Br J Nurs. 2017;26(3):159-165. doi:10.12968/bjon.2017.26.3.159 ↩︎

  53. Catlin AC, Malloy WX, Arthur KJ, et al. Comparative analytics of infusion pump data across multiple hospital systems. Am J Health-Syst Pharm. 2015;72(4):317-324. doi:10.2146/ajhp140424 ↩︎ ↩︎ ↩︎

  54. Walroth TA, Smallwood S, Arthur K, et al. Development of a standardized, citywide process for managing smart-pump drug libraries. Am J Health-Syst Pharm. 2018;75(12):893-900. doi:10.2146/ajhp170262 ↩︎ ↩︎

  55. DeLaurentis P, Walroth TA, Fritschle AC, et al. Stakeholder perceptions of smart infusion pumps and drug library updates: a multisite, interdisciplinary study. Am J Health-Syst Pharm. 2019;76(17):1281-1287. doi:10.1093/ajhp/zxz135 ↩︎ ↩︎

  56. Joseph R, Lee SW, Anderson SV, Morrisette MJ. Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. Am J Health-Syst Pharm. 2020;77(15):1231-1236. doi:10.1093/ajhp/zxaa164 ↩︎ ↩︎

  57. Roydhouse SA, Carland JE, Debono DS, et al. Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions. Br J Clin Pharmacol. 2021;87(11):4273-4282. doi:10.1111/bcp.14844 ↩︎

  58. Suess TM, Beard JW, Trohimovich B. Impact of patient-controlled analgesia (PCA) smart pump-electronic health record (EHR) interoperability with auto-documentation on chart completion in a community hospital setting. Pain Ther. 2019;8(2):261-269. doi:10.1007/s40122-019-0132-2 ↩︎

  59. Wei W, Coffey W, Adeola M, Abbasi G. Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital. Am J Health Syst Pharm. 2021;zxab287. doi:10.1093/ajhp/zxab287 ↩︎

  60. Bechdel BA, Bardman KJ, Machemer C. Developing a nurse-driven vascular access device order set using the electronic medical record. J Infus Nurs. 2022;45(1):20-26. doi:10.1097/nan.0000000000000450 ↩︎

  61. Agency for Healthcare Research and Quality. How to build sustainability into the improvement process. 2014. https://www.ahrq.gov/hai/tools/mvp/modules/technical/sustainability.html ↩︎

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