Header

UZH-Logo

Maintenance Infos

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


Vetter, Luzia; Schuepfer, Guido; Kuster, Stefan P; Rossi, Marco (2016). A Hospital-wide Outbreak of Serratia marcescens, and Ishikawa's "Fishbone" Analysis to Support Outbreak Control. Quality management in health care, 25(1):1-7.

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.

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.

Statistics

Citations

4 citations in Web of Science®
2 citations in Scopus®
Google Scholar™

Altmetrics

Downloads

23 downloads since deposited on 21 Oct 2016
23 downloads since 12 months
Detailed statistics

Additional indexing

Item Type:Journal Article, refereed, further contribution
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Clinic for Infectious Diseases
Dewey Decimal Classification:610 Medicine & health
Language:English
Date:1 September 2016
Deposited On:21 Oct 2016 11:39
Last Modified:04 Aug 2017 00:37
Publisher:Lippincott Williams & Wilkins
ISSN:1063-8628
Free access at:PubMed ID. An embargo period may apply.
Publisher DOI:https://doi.org/10.1097/QMH.0000000000000078
PubMed ID:26783861

Download

Download PDF  'A Hospital-wide Outbreak of Serratia marcescens, and Ishikawa's "Fishbone" Analysis to Support Outbreak Control'.
Preview
Content: Published Version
Filetype: PDF
Size: 899kB
View at publisher