Journal
QUALITY MANAGEMENT IN HEALTH CARE
Volume 25, Issue 1, Pages 1-7Publisher
LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1097/QMH.0000000000000078
Keywords
Ishikawa's fishbone analysis; outbreak control; Serratia marcescens
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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.
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