Poor/Improper

Technique

Line Colonization/
Contamination

Lack of hand
hygiene

Blood left
In line/end cap

Chloraprep
not used for
skin prep
prior to
line insertion

Dressing not
changed on time

Multiple attempts

Breaks in sterile
technique

Line not needed

but not removed

More than
one
central venous
catheter

Treatment based
On false positive
/contaminated
blood cultures

Resident unfamiliar
with policy
Nurses do not know
dressing change
due; no dates on dressing
Policies not written
or not current
Supplemental
staff unaware of
policy/lack training

Medical staff not

supportive of policies

Antibiotic
Usage

Catheter-Related
Bloodstream
Infection
Internal
jugular or
femoral
site used

Inexperienced clinicians

Policy unavailable
to medical staff

Number of
Catheters and/or
Lumens

TPN infused
via existing line

Blood left
in end caps

Inadequate
draping prior
to insertion

Antibiotic use
outside
hospital
guidelines

Inappropriate use of
ultrasound devices
during line
insertion

Vascular
end caps
not changed

Poor technique when

obtaining blood cultures

Blood cultures
drawn through
line and
results
questionable

Dressing changes
done without
appropriate
supplies

Blood at
insertion
site not
removed

Line manipulation

More lumens on
line than needed

IVF and components

not changed
according to policy

Line from ED/

field not changed

Dressing not
occlusive

Line accessed without

clean technique including
alcohol swabbing of access site

Investigating
Practices to
Prevent CR-BSI

IV tubing hanging
without covered end

No gown, mask,
gloves or hair
covering during
insertion

Line inserted
without
using sterile
technique

Contaminated
Supplies

Education

Insertion
site near
tracheostomy
Other
opportunity
for dressing
Contamination

Line inserted
via undesirable
site (i.e., femoral)
not changed

Nurses too
busy to change
dressing
MD inserts
line alone-too
busy to get
nurse assistance

Supplemental
nursing staff

Inexperienced
nursing staff

Line in place
but no longer
needed

Site Selection

Staffing
Acuity/Time