JCI-ASP Toolkit Module 1 (rev6) low res

Preventing Infections in the
Operating Theater and Central
Sterile Supply Department
MODULE #1
Global Challenges in
the Prevention of Health
Care–Associated Infections
Barbara M. Soule, RN, MPA, CIC, FSHEA

© 2015 by Joint Commission International / Joint Commission Resources 2
MODULE #1
Global Challenges to
Prevention of Health
Care–Associated
Infections
THIS JCI PROGRAM IS SPONSORED BY ASP.
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George Allen, PhD, CIC, CNOR
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MODULE #1
Contents
a. Overview and Learning Objectives
b. A Brief History of Health Care-Associated Infections
c. Effective and Participative Leadership
d. A Patient Safety Culture
e. Evidence-Based Practice
f. Measurement
g. Multidrug Resistant Organisms and Antimicrobial Stewardship
h. Summary
i. References

MODULE #1
a. Overview and
Learning Objectives
Health care–associated infections (HAIs) are a global public health issue that has existed for thousands of years. HAIs have resulted
in harm to patients in most health care settings, including hospitals, long term care facilities, and ambulatory surgery, outpatient
diagnostic, and treatment clinics/centers. The infections are a risk to patients and staff members in the health care environment.
HAIs cause significant morbidity and mortality and often result in increased medical costs for patients and families, loss of wages
for families, and significant costs to health care systems. HAIs may also have negative effects on local or national economies.
Although significant improvements have been made in preventing and controlling infections, disparate countries have implemented
recommended practices unevenly because of dramatic differences in human and material resources, politics, and regulations.
This module presents an overview of HAIs:
• A brief history of HAIs
• The current global status of HAIs
• The infection challenges common to most countries
• The strategies to minimize or eliminate risk associated with these challenges
The module summarizes the critical role of leadership, evidence-based practices, patient safety, the environment, measurement,
performance improvement, and emerging infections. Many of these issues are discussed more thoroughly in succeeding modules.
After reviewing this module, the reader will be able to:
• Discuss a brief history of HAIs.
• Describe the global status of HAIs.
• Explain the endemic burden of HAIs in developing countries.
• Discuss global challenges for HAIs.
• State potential prevention strategies for global infection issues.
Attention to HAIs and infection prevention is increasing worldwide. Many countries have implemented systematic efforts to improve
infection prevention and control (IPC) practices and outcomes. In emerging economies initiatives exist to reduce infections through
better education and training of staff members, patients, and infection prevention specialists. These initiatives often include
implementing evidence-based practices demonstrated to prevent infections and improve care. In developed economies with
sophisticated health care infrastructures, the focus is to benchmark best practices, to meet or exceed them, and to create mandates
for evidence-based IPC practices. Many countries have also increased infection prevention research to determine best practices and
have expanded efforts to improve understanding of the human (behavioral) aspects of preventing HAIs.
Efforts are made, though not always successfully, to implement practices such as hand hygiene, appropriate use of protective
measures with patients who have suspected or known communicable diseases, management of instruments and supplies, appropriate
use of invasive devices, and improved surgical practices (or processes). Evidence-based practices have also found their way into the
design of health care facilities.1
Although organizations are encouraged to set targets of zero practices that may lead to infections
or to zero infections, we are far from achieving this goal.2
Implementation science is gaining support in the global community with
strategies such as checklists that have been used to support, trigger, and remind health care workers to implement key steps in
recommended practices to prevent infection.3
These efforts, such as with eliminating central line related infection, have had wide
success, have been noted in policy-making bodies, and are being implemented by many health care organizations. Implementation
science describes and promotes methods to integrate evidence-based practices in clinical areas. It is an area of knowledge relatively
new to the field of IPC but is now available to support IPC practice.4
This methodology will be discussed later in this module.
In addition to implementation science, infection preventionists
and health care epidemiologists have become more involved
in learning and using performance improvement and patient
safety methods to enhance infection prevention practices. These
topics will be discussed later in this module and more fully in
Module 2, Leadership, Module 6. Performance Improvement and
throughout the toolkit.
Definition: Health Care-associated Infection (HAI)
A health care-associated infection (HAI) is a localized or systemic
condition resulting from an adverse reaction to the presence of an
infectious agent(s) or its toxin(s) that was not present on admission
to the acute care facility.
- Centers for Disease Control and Prevention
LEARNING OBJECTIVES
INTRODUCTION

Medicine and public health have been concerned about transmission of infection for centuries. The idea of preventing HAIs is reflected
in the well-known admonition to physicians to “first, do no harm,” which is the cornerstone of the Hippocratic oath.5
Infections that
occur in association with health care provided in hospitals, long term care facilities, and outpatient clinics are particularly onerous,
because the patient did not have an infection upon entering the hospital or other health care organization but acquired it while in the
setting and receiving care. To fully understand the transmission of infection in hospitals, it is helpful to create the context in which
HAIs occur. We can do this by reviewing the history, evolution, and role of the hospital.6
MODULE #1
b. A Brief History
of Health Care-
Associated Infections
Early in history there were “places of healing” in the Roman
and Greek empires (4000 BCE), and in India and Sri Lanka (200
BCE). These settings may have been a combination of places of
healing, places to house the poor, or places of rest for the weak
and dying. No thought was given to treatment or cure, only to
support patients in their illnesses.
Hospitals arose in Europe in the Middle Ages mostly in
monasteries, which often allocated space in their building(s)
to infirmaries, houses for physicians, houses for bleeding, and
bath houses. In the later Middle Ages, guilds and parishes began
to care for their sick. Parish care gradually evolved into health
services provided by lay citizens, and by the end of the fifteenth
century, Europe had developed a large network of hospitals
managed by local authorities. Mainly the poor and underserved
used hospitals during this time; the upper classes received their
care at home.7
The Hotel Dieu Hospital in Paris was founded in the seventh
century (see Figure 1-1). For a period, it was the only hospital
in the city, and it survived and expanded over hundreds of years.
By the eighteenth century the hospital was large and crowded. It
had about 1,000 beds, but never housed fewer than 2,000-3,000
patients.8
Estimates show that during French epidemics, the
number of patients at Hotel Dieu Hospital topped 7,000, with as
many as eight patients sharing one bed at a time and with beds
that were sometimes occupied in shifts.8
At Hotel Dieu infection prevention techniques were mostly
absent from care. For example, patients’ wounds were washed
each day with a single sponge used from patient to patient. Thus
almost all wounds became infected.9
Mortality from amputations
was nearly 60%, in large part due to infection. Drinking water for
patients came directly from the River Seine without benefit of
processing. Puerperal fever (postpartum endometrial infection)
was very common at this time, and in one epidemic in 1746, 19
of 20 women who became infected died.9
This may be attributed
partly to the fact the maternity ward was in the hospital basement.
Dirty water and garbage were deposited on the floor of the ward
whenever the river rose, ensuring an unclean environment for
In the eighteenth century British hospitals seemed more aware
of the role of cleanliness and sanitation in safe patient care. The
hospitals were generally cleaner. For example, in 1771, patients
who were admitted to one British infirmary received clean sheets
upon admission and at least one other set of sheets every three
weeks. Also, hospital policy stated that two patients were not to
be placed in the same bed unless no other option existed.10
Most physicians did not know about or accept the germ theory of
disease until after the pioneering work of Dr. Robert Koch (see
Figure 1-2) and Dr. Louis Pasteur (see Figure 1-3). Koch (1843-
1910), a microbiologist, first isolated tuberculosis, cholera,
and anthrax organisms, and developed Koch’s Postulates of
the germ theory.11
Pasteur (1822-1895), a French chemist
and microbiologist who also recognized the germ theory,
used it to create vaccines and other treatments.12
Afterward,
some physicians understood that specific diseases could be
transmitted among hospitalized patients.
Source: Wikimedia. Hotel Dieu. Accessed Oct 3, 2014.
Figure 1-1. Hotel Dieu Hospital in Paris
PLACES OF HEALING
CLEANLINESS AND SANITATION
OF THE ENVIRONMENT
patients. From the circumstances at Hotel Dieu, it is apparent
that hospitals were not the safest places for patients in the
Middle Ages. Yet, the worse alternative for the homeless or poor
was being ill on the city streets, with no care at all.

However, doctors were not aware of the route of transmission and often attributed the cause of disease to “bad air,” “effluvia,” or
“miasmas.” Some hospitals did start using segregation (isolation) for patients who posed transmission risks. In the Middle Ages
segregation was used for leprosy patients, who were placed in leprosariums, and in the fifteenth century for plague victims, who were
put in lazarettos (quarantined settings). Fever hospitals were established in England in the early nineteenth century to segregate
smallpox and fever cases.10 The value of isolation in preventing transmission was perhaps first clearly demonstrated in a study
published in 1864. Another study compared a general hospital with a fever hospital. The investigator found that typhus spread easily
in the general hospital. For approximately every four typhus patients admitted to the general hospital, there was nosocomial spread
to one patient. In contrast, for every 40 patients with typhus admitted to the fever hospital, where isolation was practiced, there was
also only one case of nosocomial spread, a tenfold difference in these two care settings. This difference indicated that isolation
practices were effective in reducing spread of the infection.13
MODULE #1
b. A Brief History
of Health Care-
Source: Wikipedia. Robert Koch.
Accessed Oct 3, 2014.
Figure 1-2. Dr. Robert Koch
Source: Wikipedia. Ignaz
Semmelweis. Accessed Oct 3, 2014.
Figure1-4.IgnazSemmelweis,MD
Source: Wikipedia. Louis Pasteur.
Figure 1-3. Dr. Louis Pasteur
Source: Wikipedia. Joseph Lister.
Figure 1-5. Joseph Lister, MD
No discussion of the history of infection prevention and control
in hospitals would be complete without mentioning Dr. Ignaz
Semmelweis (see Figure 1-4) and his remarkable work in
reducing puerperal fever among pregnant women delivering
at Vienna General Hospital. Semmelweis is often considered
“the savior of mothers.” His treatise, Etiology, Concept, and
Prophylaxis of Childbed Fever, was published in 1861.14
The
work was based on mortality outcomes associated with midwives
who delivered babies versus doctors who delivered babies. This
led to his insight that “something” was being transmitted from
autopsy rooms, where the physicians had assisted in autopsies
or handled cadaver tissue, to the uninfected women giving
birth. Semmelweis insisted the doctors wash their hands in
a solution of chlorinated lime when leaving the autopsy room
or anatomy laboratory and before examining the women. This
simple procedure reduced mortality in the physician ward from
18% to 2%, to match the ward in which only midwives delivered
babies.15
Later Semmelweis began washing instruments as
well, and mortality decreased to 1%. In 1843, Oliver Wendell
Holmes published his essay on the “Contagious Nature of
Puerperal Fever,” in which he identified puerperal sepsis as a
contagious disease. He also recommended measures to reduce
the spread of infection.16
The acknowledgment and acceptance of
Semmelweis’s and Holmes’s work did not occur until two decades
after Semmelweis’s death, when Koch and Pasteur produced
evidence of the germ theory and British surgeon Joseph Lister
(see Figure 1-5) of antisepsis. Then both Semmelweis and Holmes
were credited for their excellent analysis and infection reduction.

MODULE #1
b. A Brief History
of Health Care-
Florence Nightingale’s (see Figure 1-6) enormous success in reducing infections and
mortality in military personnel in the Crimean War (1854-1856) occurred because
she was able to demonstrate to the military authorities that providing patients with
safe food and water, and maintaining personal hygiene and clean environment in the
wards could (and did) result in major reductions in deaths from HAIs.17 Nightingale
felt strongly that there was a direct relationship between the sanitary conditions of
wards and hospitals, and postoperative infections, erysipelas (group A streptococcal
infection), pyemia (organisms in the blood–septicemia) and other complications, such as
gangrene.17
In 1856, Nightingale met William Farr, the premier statistician in England,
and eventually they worked together for more than 20 years because of their mutual
interest and passion for data. Together they made significant strides in reducing HAIs
by demonstrating through statistical analysis that the increased mortality in military
personnel was significantly due to crowding and contagious diseases transmitted in
the wards. Nightingale’s insistence on collecting infection data and analyzing it using
basic statistical measures may be the first example of surveillance of HAIs by a nurse.7
patients. From the circumstances at Hotel Dieu, it is apparent that hospitals were not
the safest places for patients in the Middle Ages. Yet, the worse alternative for the
homeless or poor was being ill on the city streets, with no care at all.
It is likely that Joseph Lister, a pioneer of antiseptic surgery, read the work of Semmelweis and Holmes during his surgical career.
Lister dramatically reduced HAIs in surgical patients. He thought microbes might be responsible for infections (such as wound
suppuration) and that by killing organisms in wounds he could prevent surgical infections and death. He used carbolic acid on
dressings to pack the wounds of patients with compound fractures. The prospect for recovery in these patients was generally grim.
Additionally he soaked sutures and even his fingers in carbolic acid, and sprayed the operating theater with to kill germs in the air.18
He published his findings in 1867, and the evidence of decreased infections in his surgical population was so compelling that his
techniques gained acceptance in the next decades. His surgical asepsis principles stand today in the operating theater.
By 1910, sterile instruments, gowns, and gloves and masks were standard in many large teaching hospitals. The original use of
rubber gloves was to protect the hands of the surgical team from carbolic acid. However, the role of gloves in protecting patients
from microorganisms on the hands of health care workers was recognized, and gloves became standard garb where available.
Sterilizers were introduced, and they were fundamental to the preparation of sterile instruments and devices that protected most
patients from surgical infections. In some clinics staff silence during surgery was required to limit bacterial contamination thought
to be spread by talking. Gradually, some physicians began to keep records of infections and use active surveillance systems to track
surgical infection trends.19
Each decade has brought changes in our knowledge about how organisms are transmitted within the health care setting. One of
the first HAIs addressed in a 1929 study was catheter-related urinary infections by Cuthbert Dukes, MD.20
This study described the
pattern of urinary infections in patients having rectal surgery who also had an indwelling urinary catheter. The researcher stressed
that depending on the duration the catheter was indwelling in the bladder, there was certainty that infection would occur and that
there was some predictability on how long it would take for the infection to develop. Dukes tested several urinary drainage systems
and was able to find one that decreased infection by 66%. Dukes’s finding may have influenced the development of urinary drainage
systems throughout the twentieth century.
DATA COLLECTION
ANTISEPSIS AND STERILIZATION
TWENTIETH CENTURY DEVELOPMENTS
Source: Wikipedia. Florence Nightingale.
Figure 1-6. Florence Nightingale, RN

As with other HAIs, as our understanding about their causes and mechanisms of transmission have increased, there have been
improvements in reducing central-line associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP).
Although CLABSI and VAP were once thought to be inevitable consequences of the care of critically ill patients, decreases in these
infections have occurred through the use of careful aseptic and sterile techniques and reducing the length of time that the central
line or ventilator is used for patient care. These device-associated infections are no longer considered inevitable for many patients.
The shift in thinking is that nearly all of these infections are preventable. The implementation of “bundles,” a group of three to five
evidence-based risk reduction practices, used simultaneously and consistently with central lines, urinary catheters and ventilators
has driven dramatic declines in infections related to these devices.3,21
See Table 1-1, below, for an example of a “bundle” for central lines.
The advent of antibiotics brought about a major change
in controlling and treating HAIs. Sulfonamides were used
successfully after World War II to treat staphylococcal and
streptococcal infection. When penicillin was discovered in 1929
by Alexander Fleming and developed into an antibiotic in 1941,
it was viewed as a panacea for infection and generally lived up
to this claim for many years. More recently the inappropriate
use or abuse of antibiotics paired with the decline in effective
antimicrobial drugs has created a worldwide public health
problem that will be discussed later in this module.
Table 1-1. Key Elements of the IHI Central Line Insertion Bundle21
MODULE #1
b. A Brief History
of Health Care-
In the late 1950s and early 1960s, a pandemic of Staphylococcus aureus infections in American and European newborns led to
changes in nursery practices. At the time family members of a woman in delivery were not allowed to be with the woman, and strict
protocols (rules) said only hospital personnel could handle infants. All infants were housed in large multi-crib nurseries. Eventually
scientists understood that the newborns were being exposed to S. aureus through contact with organisms on the hands of hospital
nurses and doctors. Strict hand washing with antimicrobial soap was implemented in newborn nurseries. S. aureus infections in
nurseries (and in surgical patients) in the 1950s and 1960s led to improved methods of newborn care, which included improved
cleaning in the nursery, the initiation of cohort (grouped) nursing, and later “rooming-in” (having the baby stay in the room with the
mother rather than in the nursery). Efforts were also made to decrease the babies’ length of stay in the nursery to less than three
days to lower risk of colonization from other infants.22,23
Still, the S. aureus outbreak took years to control.
Subsequently, hospitals recognized the need for a sister/nurse in England or a nurse in the United States, and later physicians, to
oversee infection prevention practices. This initiative evolved into new professional roles and a new discipline for the infection control
practitioner (infection preventionist), and hospital or physician health care epidemiologist.23-25
Although most HAIs are endemic, periodic outbreaks have provided valuable information by raising awareness of specific risks
and by contributing to the understanding of specific factors that increase risk of infection.26
New knowledge about causes of these
outbreaks have been integrated into routine strategies for preventing and managing infections. Contamination of intravenous fluids
and subsequent sepsis and mortality of neonates is an example of one such epidemic.27,28
More contemporary outbreaks are related
to defective or inadequately cleaned equipment (and/or the environment), such as bronchoscopes29
or central line connector valves.30
In the United States, this led to process changes in cleaning, disinfecting, and sterilizing or producing equipment that have improved
safety and reduced risks of infection. Similar outbreaks occur globally on a regular basis.
The understanding of HAIs and the epidemiology that has led to new knowledge continues to grow. Some developing countries with
emerging economies are beginning to provide preventive, curative, or life enhancing procedures to large segments of their populations.
These procedures extend life expectancy, but may also include an increase in chronic diseases of the elderly and expand the use of
invasive procedures and technologies. Interestingly, these changes in health care outcomes may also increase the risk of HAIs.31
EVOLUTION OF THE ROLE OF THE INFECTION PREVENTIONIST
TWENTY-FIRST CENTURY EVENTS
• Hand hygiene
• Maximal barrier precautions upon insertion
• Chlorhexidine skin antisepsis
• Optimal catheter site selection, with avoidance of the
femoral vein for central venous access in adult patients
• Daily review of line necessity with prompt removal of
unnecessary lines

MODULE #1
b. A Brief History
of Health Care-
Information about the incidence of endemic HAIs in developing countries has been slow to be published. A 2010 article by Allegranzi,
et al., discussed the burden of endemic HAIs in developing countries.32
In this systematic review and meta-analysis, the authors
found that the prevalence rate of infections in low- and middle-resource settings averaged 15.5 infections per 100 patient days
compared with a prevalence of 7.1 infections per 100 patients in Europe, and 4.5 infections per 100 patient days in the United States.
Even more alarming was the incidence of infection rates in the ICUs of developing countries of 47.9 per 1,000 patient days compared
with 13.6 infections per 1,000 patient days in the United States. Neonatal infections were found to be three to 20 times higher in
the developing world,33
and the risk of surgical site infections (SSI) is also higher (for example, 5.6 per 100 surgical procedures in
developing countries compared with 2.6, 2.9, and 1.6 infections per 100 surgical procedures in the United States, European countries,
and Germany).32
In some developing countries, as many as 70% of injections administered are considered unnecessary and use unsafe injection
practices (such as the reuse of disposable, one-time injection devices). This accounts for almost 250,000 new HIV infections per
year. The 2008 European Centre for Disease Prevention and Control report estimates that HAIs are associated with 16 million extra
hospital days and 37,000 attributable deaths annually.34-36
Clearly there are continuing challenges for HAIs worldwide.
Another concern relates to the costs of HAIs. It is hard to obtain cost data from various countries because average costs of HAIs will
differ depending on the type of infection and prevalence in a hospital, the infection rate, and the cost of health care in the country.37
The
methodology to calculate costs varies from physician-generated data to sophisticated economics methods that include consideration
of direct and indirect hospital costs.38
This makes comparisons difficult if not impossible in most cases. Table 1-2, below, delineates
the different factors for calculating costs of HAIs in hospitals.
Adapted from: Centers for Disease Control and Prevention (CDC). The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and
the Benefits of Prevention, March 2009. Scott RD, II. Accessed Oct 3, 2014.
http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf
Table 1-2. Factors for Calculating Costs of HAIs in Hospitals
Direct Costs in Hospitals
Indirect Costs in Hospitals
Intangible Costs
Lost Wages, Decreased Productivity, Family Burden (lost income, additional
care costs), Increased Morbidity (illness) or Mortality (death), Decrease or Lost
Leisure Time
Fixed Costs
Buildings, Utilities,
Equipment and Technology,
Labor of Personnel
Variable Costs
Food, Medications, Treatments and Procedures,
Devices, Consultations and Additional Laboratory
and Radiographic Support, Supplies
Psychological (anxiety, grief, disability, loss of job), Pain and Suffering,
Alterations in Daily Activities and Social Functioning
CURRENT DATA
HAI COSTS

However, some cost data are available. Information from HAIs in the United States has been collected for many years, and the
Centers for Disease Control and Prevention (CDC) regularly publishes costs based on hospital reports. A 2010 report from the CDC,
The Direct Medical Costs of Infections, used two methods to calculate the annual direct medical costs for HAIs.38
The range of costs
reported for HAIs annually was from US $28.4 to US $45 billion in 2007 dollars, depending on the technique used for calculations
(see Table 1-3, below). As a corollary, HAI prevention costs were calculated as US $5.7 to US $31.5 billion, again depending on
methodology. What is evident in these cost data comparisons is that prevention activities cost less than treating infections and would
potentially save billions of dollars if implemented.
Costs of infections in the global community are hard to discern. For example, infection costs in New Zealand for medical and surgical
patients were estimated at more than US $23 million for medical patients and US $38 million for surgical patients admitted to
all hospitals there per year.39
In Switzerland, a study of the extra length of stay and costs attributed to health care-associated
bloodstream infections in critically ill patients estimated that extra costs for the infection averaged US $40,000 for each person who
survived.40
A study from Singapore evaluated the direct clinical and financial impact of health care-associated methicillin-resistant
Staphylococcus aureus (MRSA) infections in hospitals there.41
Researchers found that MRSA infections were associated with higher
hospital costs (US $18,129 for infected patients versus US $4,490 for non-infected patients). In an Iranian cardiac surgical unit,
researchers found that excess direct medical costs for infected patients was double that of those without HAIs.42
The differences in
these figures illustrate the challenge of identifying trends in costs of HAIs throughout the world.
Note: CPI – Consumer Price Index
Adapted from: Centers for Disease Control and Prevention (CDC). The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and
the Benefits of Prevention, March 2009. Scott RD, II. Accessed Oct 3, 2014.
http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf
MODULE #1
b. A Brief History
of Health Care-
Table 1-3. Average Attributable per Patient Costs of HAI by Selected Sites of Infection
Infection Site
SSI
CLABSI
VAP
CAUTI
CDI
Low Estimate of
average attributable
Costs ($ base year)
$10,44318
(2005)
$5,74319
(2003)
$11,89720
(1999)
$58921
(1998)
$5,04222
(2003)
Low estimate
adjusted to 2007
$ using CPI-U
$11,087
$6,461
$14,806
$749
$5,682
High Estimate of
average attributable
Costs ($ base year)
$25,5463
(2002)
$22,9319
(2002)
$25,07218
(2005)
$75818
(2002)
$7,17922
(2003)
High estimate
adjusted to 2007
$ using CPI-U
$29,443
$25,849
$27,520
$832
$8,090

MODULE #1
b. A Brief History
of Health Care-
As described above, there is increasing global concern about HAIs as a patient-safety issue, especially as these adverse events are
associated with additional morbidity, mortality, and excess costs.43
HAIs occur in patients in hospitals and other health care settings,
such as long term care, primary health care, special clinics, and outpatient and surgical settings where patients receive diagnostic
and therapeutic care. Therefore, a primary responsibility of all health care providers and support staff is to protect patients and staff
members from HAIs.
Health care delivery in all countries carries with it similar infection risks, such as those associated with invasive devices and
procedures, hand hygiene, and environmental cleanliness, although the degree of risk and the outcomes vary from one country to
another.32
As years of life are increased through better care, patients who live longer may become immunocompromised and more
susceptible to infections in their communities and in the health care setting. Many microorganisms are increasingly resistant to the
available drugs with fewer new drugs in sight to treat the infections caused by these organisms. Technology is used more often in
health care and brings with it both benefits and hazards.44,45
Complex care processes often involve invasive procedures that increase
infection risk, and the care environment (acute or non-acute settings) can be a reservoir for infectious agents that can be transmitted
to patients. In many countries resources for care are limited, which may hinder attempts to use best practices. Often patients remain
in hospitals or long term care facilities for extended periods, which increases their risk of developing an HAI from exposures to
microorganisms from their treatment, contact with health care personnel, other patients, or the hospital environment. Health care
professionals are also at risk for infections from patients and the work environment. Many of these factors may be occurring at the
same time, which complicates and compounds prevention efforts.
Each country, region, and organization has its own culture of patient care, quality and safety, as well as resources that influence how it
views and addresses infection risk. Basic infection prevention strategies have common themes worldwide and unique characteristics
depending on the circumstances of the country and the particular organization. The following discussion addresses some global
infection prevention challenges and strategies to reduce HAI risks. Many risks will be further described in succeeding modules (see
Sidebar 1-1, below).
GLOBAL STRATEGIES TO PREVENT HAIS
Sidebar 1-1. Global Infection Challenges and Strategies to Reduce Infection Risk in Health Care Organizations
• Leadership: strong, visible, proactive
• Infrastructure:physicalstructuresandhospitaldesign,policiesandprocedures,education,staff,resources,equipment,supplies
• Culture of Patient Safety and Performance Improvement: no blame, zero tolerance; organizational learning; trained,
competent staff; transparent communication
• Evidence-Based Practices and Interventions: for direct patient care and support services
• Environment of Care: effective cleaning and disinfection of the patient care environment, proper management of
medical equipment, air and water supplies, and medical waste
• Measurement: surveillance and cluster or outbreak investigation; effective, timely
• MDROs and appropriate use of antimicrobial agents and antimicrobial stewardship programs
• Emerging and reemerging diseases and epidemics

MODULE #1
c. Effective and
Participative
Leadership
Health care organizations and leaders in all countries must make IPC a priority. It is critical that leaders understand the potentially
severe risks of illness or death to patients and employees from HAIs, as well as costs to the organization for caring for HAIs. Leaders
have among their many tasks the responsibility to establish and maintain a culture of patient safety and with that the responsibility
to provide the infrastructure and resources that support the best infection practices.46,47
A culture of safety and strong leadership starts with a mission and vision for the hospital
or long term care facility. Creating the organization’s vision, mission, and core values is a
critical component of a leader’s responsibility to guide the organization toward its strategic
goals and help facilitate alignment between leaders and staff members to enhance patient
care.46
The health care organization’s mission establishes the general direction of the
organization, defining its fundamental purpose, and describing why it exists and what it
will do to achieve its mission. The mission leads the organization to its current goals and
objectives that must be described in clearly written policies and procedures to provide
guidance for infection prevention practices among staff members, visitors, and others.
Vision statements should also be concise, as well as inspirational, clear, and memorable to be of the most value. The vision statement
helps to describe and guide the organization toward the future. The vision communicates where and what the organization strives to
be in a few years’ time and what the organization is working toward as its potential to achieve even better outcomes of care.
Many organizations also state their core values. These are values that guide the behavior of every employee in the organization. See
Table 1-4, below, for examples of mission statements, vision statements, and core values, which are also discussed in Module 2.
Table 1-4. Examples of Mission Statements, Vision Statements, and Core Values
Leaders can support infection prevention by becoming knowledgeable in these areas:
• the IPC program
• the critical role it plays in patient safety
• the ways to prevent or minimize HAIs
An important responsibility of organizational leaders is to make informed decisions about patient care and staff member safety
relative to infection prevention. To make informed decisions, leaders must have valid and reliable data about infection risks, clinical
outcomes, and financial consequences. Therefore, leaders should expect to receive risk assessments for infections and infection
data that have been carefully collected, analyzed, and presented to assist them in supporting best practices decisions or making
changes when necessary.
Remember This!
The most effective mission
statements describe the reason
an organization or program
exists and are used to help
guide decisions about priorities,
actions, and responsibilities.
Mission Statement Examples:
• To contribute to the health and well-being of every patient by providing the best care through integrated clinical practice,
education and research.
• To promote awareness about the importance of infection prevention and control measures of health care providers,
patient and visitors; to make infection prevention part of their daily practice; to prevent infections, ensure a safe working
environment for employees and a safe care environment for patients.
Vision Statement Examples:
• To achieve the best infection prevention and control in the country.
• Striving to be the world’s leader in positive patient experience, clinical outcomes, research, and education.
Organizational Core Values Examples:
• Honesty, Trustworthy, Caring, Patient-Centered, Respectful, Service Focus

Sidebar 1-2. How Can IPC Personnel Gain Leadership Support for the IPC Program?47,51
• Communicate with leaders about infection prevention activities.
• Provide leaders with analyzed surveillance data in an easy-to-understand format.
• Provide regular reports of activities; focus on achievements, problems, and solutions.
• Send minutes from the IPC committee to the leader(s) – or other committee that discusses infection prevention issues,
for example, OT, CSSD, Nursing.
• Invite a leader to meet with the IPC team to discuss issues or to meet with another team with infection issues.
• Encourage a leader to make environmental rounds with the IPC team.
MODULE #1
c. Effective and
Participative
Leadership
Clearly, it is the leaders’ responsibility to lead and support the adoption and implementation of a culture of safety in the organization.
Whether the administrator, chief nursing officer, chief medical officer or others, the initiative must originate from this group. Then
the leaders of departments and services, and staff can integrate the culture knowing their leaders will support them.
Leaders should attend IPC committee meetings if possible or designate a leader representative, and they may periodically
participate in environmental rounds, discuss infection prevention at management meetings, and serve as role models by following
IPC recommended practices, such as performing appropriate hand hygiene. It is important for leaders to provide the needed
infrastructure and resources for the IPC program, such as hand hygiene supplies, rooms with negative pressure for isolating patients
with airborne communicable disease, and staff education.47
The IPC program also needs resources to function effectively, such as
an office, access to medical information, training, and preferably computers. Lack of these resources inhibits the implementation of
best practices.48
Adequate numbers of well-trained infection prevention personnel49,50
and education and training for all appropriate
clinical and support staff members, sufficient supplies, such as hand hygiene facilities (soap, water, towels or alcohol-based rubs,
and environmental safety) are ultimately the leaders’ responsibility.
Leadership effectiveness for infection prevention is a two-way process. Infection prevention personnel must establish a relationship
with their leaders and work within the culture of their organization(s) to emphasize the critical role of the infection prevention
program in supporting and facilitating the group’s mission and goals. This type of interaction and communication is more likely
to create the best relationship and maximize support for infection prevention. Sidebar 1-2, below, lists some activities that IPC
personnel or staff members interested in infection prevention in any organization can undertake to obtain leadership cooperation
and assistance for the IPC program and efforts.
Leadership will be discussed in greater detail in Module 2.
In developed, economically stable countries, most hospitals have essential supplies, adequate processes, and systems to identify
and analyze HAIs to implement appropriate prevention measures. However, in many countries, the health care infrastructure is only
nominal, and the absence of equipment, supplies, staff members, and clear policies are major barriers to preventing infections.52-54
Hospitals may even vary in resources within countries, with some hospitals fully equipped and others having barely adequate
supplies. Scheckler, et al., developed nine recommendations for an infrastructure for infection prevention and control programs that
can serve as a guide for organizations:47
1. Surveillance of nosocomial infections must be performed.
2. Surveillance data must be analyzed appropriately and used to monitor and improve infection control and health care outcomes.
3. Clinical performance and assessment indicators used to support external comparative measurements should meet the
criteria delineated by SHEA and APIC.
4. Written infection prevention and control policies and procedures must be established, implemented, maintained, and
updated periodically.
5. Policies and procedure should be monitored periodically for performance.
6. Health care facilities should use infection control personnel to assist in maintaining compliance with relevant regulatory and
accreditation requirements.
INFRASTRUCTURE

MODULE #1
c. Effective and
Participative
Leadership
7. Infection control personnel should have appropriate access to medical or other relevant records and to staff members
who can provide information on the adequacy of the institution’s compliance with regard to regulations, standards, and
guidelines.
8. The infection control program should collaborate with, and provide liaison to, appropriate local and state health departments
for reporting of communicable disease and related conditions and to assist with control of infectious diseases.
9. The infection control program personnel should work collaboratively with the facility’s employee health program personnel.
A checklist is provided as Tool 1-1.
Health care facilities with a less developed infrastructure may lack adequate clean water and food for patients, as well as sinks for
hand washing, soap or alcohol gel, or alcohol-based hand rub.55
Overcrowding, insufficient technology, and a shortage of trained staff
members are frequently found in countries with limited resources. For example, in some countries or regions, hospitals may not have
enough beds for patients and may place two to four babies in the same crib and more than one adult in a bed. This close proximity
enhances the transmission of organisms and infections. Patients often share equipment that has not been cleaned, disinfected, or
sterilized between uses. In some countries nursing care is supplemented and/or provided by the family with varying degrees of skill.
Food, medical equipment, and medications are often provided by family and are not managed to avoid infection risk. When a country’s
economy starts to improve, there may be better access to clean water, sterilizers, and other clinical aids. However, resources and
supplies may continue to be variable for some time.
Countries with a substantially low level of health care resources will often lack adequate laboratory facilities to perform needed
diagnostic tests for infections, including blood cultures or antibiotic susceptibility tests. Antibiotics may not be available to treat
patients or may only be available in limited quantities. Many organizations may also lack adequate numbers of infection preventionists
to oversee the IPC program.56
Organizations may not have the resources for disposable, single-use supplies and thus will, of necessity, reuse some items that
should be discarded after use on one person (such as needles, syringes, and surgical gloves). These unsafe practices potentially
expose patients to the blood or body fluids of previous patients with hepatitis B and C, and HIV.57
Some facilities do not have clearly
written policies and procedures. This results in staff practicing without the knowledge of best methods or the standards of the health
care organization. The absence of written policies and procedures can result in a lack of standardization of practices, a known risk
for patient safety.
In summary, hospitals vary in resources by country and also within a country. Creating the most efficient and safest infrastructure,
even in countries with limited resources, will help staff members function more effectively to reduce infection risk. Organizations
can start by identifying infrastructure improvements that can be developed easily and with little cost, such as written policies and
procedures, staff training and inexpensive supplies such as alcohol-based hand hygiene supplies made by the organizations.58
Accessible and free information on best practices, or practical tips are often available on the Internet. Other infrastructure supports
will be determined by the individual organization and their resources. A checklist is provided to help organizations assess their
infrastructure. See Tool 1-1. Specific infrastructure issues for the operating theater and the CSSD will be discussed in Modules 3, 4, and 5.

MODULE #1
d. A Patient
Safety Culture
It is well established that HAIs are one of the most frequent adverse outcomes associated
with health care delivery and a significant patient safety event worldwide. Recognizing the
HAI problem, the World Health Organization (WHO) established infection prevention as
a patient safety priority.59,60
The WHO created The World Health Alliance, which initiated
its first patient safety challenge in 2005: Clean Care is Safer Care (see Figure 1-7, to the
right).61
This safety initiative focused on hand hygiene. Through this initiative, the WHO
has successfully engaged more than 130 countries that have accepted the challenge of
improving hand hygiene compliance, including Member States in Africa, the Americas,
Eastern Mediterranean, Europe, South-East Asia, and the Western Pacific. “The combined
efforts expected under the Challenge have the potential to save millions of lives, prevent
morbidities and long-term disability for hundreds of millions of patients, and lead to
major cost savings through the improvement of basic infection control measures in any
healthcare setting, regardless of resources available or level of development.”59
In 2007,
the WHO began work on their second patient safety challenge to reduce surgical site
infections (SSIs). The Safe Surgery Saves Lives challenge has the potential to reduce
SSIs around the world.62
One of the WHO SSI Prevention Guidelines is a surgical safety
checklist to help reduce surgery related infections and death. The checklist is applicable
to the global population of patients and is presented in Modules 2 and 3.63
This checklist
approach is consistent with newer approaches to infection risk reduction strategies as
discussed previously in this module.
The WHO believes strongly that infection prevention is critical to patient safety, and they currently support multiple programs to prevent
infections. Many of these programs are described in an article by Allegranzi, et al,64
and are found in Table 1-5, below, and Tool 1-6
Program
Blood transfusion safety1
Main HAI prevention
and control topic
Prevention of transfusion-
transmissible infections
(including HIV, hepatitis
B, hepatitis C and
syphilis, and bacterial
contamination of blood
and blood products)
Objectives specifically
related to HAI prevention
and control
• To develop norms, standards,
best practice guidelines, tools
and materials relating to the
entire blood transfusion process
from donor to patient to ensure
blood safety
• To support the establishment
of sustainable national blood
programs ensuring the provision
of safe, quality blood and blood
products to all patients requiring
transfusion and their safe and
appropriate use
Main guidelines/
documents
• Blood transfusion safety:
information sheet
• Prevention of health care-
associated HIV infection: flyer
• Memory aid for blood safety
• Memory aid for good policy
process for blood safety and
availability
• Memory aid for national health
authorities: developing a
national blood system
• Universal access to safe blood
transfusion
Table 1-5. WHO Programs Focused on Health Care-Associated Infection Prevention and Control
World Health Organization (WHO). World
Alliance for Patient Safety – Global Patient Safety
Challenge 2005-2006. Accessed Oct 3, 2014.
Figure 1-7. Clean Care is Safer Care

MODULE #1
d. A Patient
Safety Culture
Program
Main HAI prevention
and control topic
and control
• To build capacity in countries
through structured training
activities, voluntary unpaid
blood donation, donor
selection, donation testing,
risk assessment and
management, data and quality
management, external quality
assessment, blood cold chain,
hemovigilance, and the clinical
use of blood
• To support the implementation
of quality system in all aspects
of blood collection, processing,
testing and clinical use,
including setting up the system
for surveillance, vigilance and
monitoring
• To support the development
of education and training
programs and to incorporate
transfusion medicine into
medical and nursing school
curricula
• To establish a global
monitoring mechanism
on safe blood and blood
products and collect, analyze
and disseminate reliable
information on blood safety and
availability
• To promote harmonization and
collaboration of international
efforts to ensure sufficient safe
blood and blood products
• To promote research and
development in the provision
and appropriate use of safe
blood and blood products
Main guidelines/
documents
• Guidelines: maintaining a safe
and adequate blood supply during
pandemic influenza
• WHO resource materials on
blood safety: CD-ROM
• The Melbourne declaration
on 100% voluntary non-
remunerated donation of blood
and blood components
• Towards 100% voluntary blood
donation: A global framework for
action.
• Developing a voluntary blood donor
program (DONOR): facilitator’s
toolkit (6 modules): CD-ROM
• Blood donor selection:
Recommendations on assessing
suitability for blood donation
• Screening donated blood for
transfusion-transmissible
infections: Recommendations for
blood transfusion services
• Memory aid for the blood cold chain
• The blood cold chain: Guide to
the selection and procurement of
equipment and accessories
• Manual on the management,
maintenance, and use of blood
cold chain equipment
• Memory aid for the clinical use
of blood
• Memory aid for clinical transfusion
process and patient safety
• Developing a national policy and
guidelines on the clinical use of
blood.
• Recommendations
• The clinical use of blood:
information sheet for clinicians
• Theclinicaluseofblood:handbook
• The clinical use of blood in general
medicine, obstetrics, pediatrics,
surgery, and anesthesia, trauma,
and burns: module
• The clinical use of blood: CD-ROM
• Memory aid for quality systems for
blood safety
• Quality management training
for blood transfusion services:
facilitator’s toolkit (5 books, 15
modules, CD-ROM)
Blood transfusion safety1
(Continued)

MODULE #1
d. A Patient
Safety Culture
Program
Main HAI prevention
and control topic
and control
Main guidelines/
documents
• Distance learning in blood
safety: flyer
• Establishing a distance learning
program in blood safety: a guide
for program coordinator.
• Safe blood and blood products:
distance learning materials
• Safe blood and blood products:
trainer’s guide
• Introductory module: guidelines
and principles for safe blood
transfusion practice
• Module 1: Safe blood donation
• Module 2: Screening for HIV and
other infectious agents
• Module 3: Blood group serology
Clean Care is Safer Care2
HAI prevention control,
in particular surveillance
and prevention of the
endemic burden of HAI,
with special focus on
hand hygiene
• To raise awareness on the
burden of HAI worldwide and the
importance of hand hygiene in
health care
• To catalyze political and
stakeholders’ commitment to
reduce HAI
• To develop technical guidance
and recommendations on hand
hygiene and infection control
measures and support their
implementationinMemberStates
• To promote and sustain hand
hygiene improvement at the
point of care, through the
SAVE LIVES: Clean Your Hands
initiative and through a network
of hand hygiene campaigning
countries–the CleanHandsNet
• To undertake reviews and report
updates related to the endemic
burdenofHAIandtopromoteHAI
surveillance and data reporting
• To evaluate the impact of
infection control interventions
to reduce the HAI burden, with
particular focus on settings with
limited resources
• To coordinate the development of
newapproachesfortheprevention
of surgical site infections
• To integrate infection control and
hand hygiene in the approach to
preventing bloodstream infection
• Guidelines on hand hygiene in
health care
• Guide to implementation of the
WHO multimodal hand hygiene
improvement strategy
• Hand Hygiene Implementation
Toolkit (32 tools):
• Tools for system change
• Tools for training and education
• Tools for evaluation and
feedback
• Tools as reminders in the
workplace
• Tools for institutional safety
climate
• Hand hygiene self-assessment
framework
• “Hand Hygiene Moment 1–
Global Observation Survey”:
summary report
• SAVE LIVES: Clean Your Hands
promotional video
• Outline action plan and top 10
tips for country/area campaigns
• Using hand hygiene
improvement tools to implement
country/area campaigns
• Report on the endemic burden of
health care-associated infection
worldwide
• Health care-associated
infections fact sheet
• Scientific publications in peer
review journals

MODULE #1
d. A Patient
Safety Culture
Program
Main HAI prevention
and control topic
and control
Main guidelines/
documents
• To support development and
strengthening of infection control
capacity and knowledge, skills
and behaviors improvement
at regional, sub-regional and
country level through the
provision of tools and materials
• To develop and coordinate
educational, training and
research activities
• To advise WHO on infection
control measures and priorities
and their integration with patient
safety strategies
Infection prevention and
control in health care3
HAI prevention and
control, in particular
prevention, preparedness,
and response to epidemics
that can be associated with
or amplified by health care
• To support infection prevention
and control capacity building in
MemberStatesthroughtechnical
assistance and development
of guidance on core elements
for national and local infection
preventionandcontrolprograms.
• To provide support to help
prevent spread of infectious
diseases through development
and dissemination of evidence-
based infection control
measures in health care settings
• To provide infection prevention
and control tools for health care
facility preparedness to respond
to pandemics and epidemics
• To coordinate the Global
Infection Prevention and Control
Network1
(GIPC Network) to
foster alignment of policies and
enhance infection prevention and
control practices worldwide
• To support Member States in
responding to outbreaks through
the WHO Global Outbreak Alert
and Response Network (GOARN)
• To develop evidenced-based
norms and standards for
antimicrobial resistance
containment strategies in health
care settings
• To support infection control
preparedness to cope with public
health emergencies
• Prevention of hospital-acquired
infections
• Practical guidelines for infection
control in health care facilities
• Infection prevention and control
of epidemic- and pandemic-
prone acute respiratory diseases
in health care. WHO interim
guidelines and an accompanying
set of implementation tools for
community and hospital health
care
• Interim infection control
recommendations for care
of patients with suspected or
confirmed filovirus (Ebola,
Marburg) hemorrhagic fever
• Core components for infection
prevention and control programs
and an accompanying set
of implementation tools for
national and local programs
• WHO policy on TB infection control
in health care facilities, congregate
settings, and households
• Natural ventilation for infection
control in health care settings
• Advice on the use of masks
in the community setting in
Influenza A (H1N1) outbreaks
• Infection prevention and
control during health care
for confirmed, probable, or
suspected cases of pandemic
(H1N1) 2009 virus infection and
influenza-like illnesses
Clean Care is Safer Care2
(Continued)

Injection safety4
Occupational health5
Prevention of blood-
borne pathogens
transmission through
unsafe injection practices
Prevention of HAI among
health care workers
• To promote the rational
use of injections and safe
practices for injections and
related procedures, including
phlebotomy, intravenous, and
fingerpick procedures
• To produce policies on the
prevention of needle stick
injuries in health care workers
and the use of personal
protective equipment following
accidental stick injuries
• To support the implementation
of the recommendation for
providing hepatitis B vaccine
for all health care workers
• To improve access to safety
engineered injection devices
and sharps containers
• To promote safe sharps waste
management
• To provide the secretariat
for the “Safe Injection Global
Network” (SIGN) aiming to
achieve safe and appropriate
use of injections worldwide
• To promote the protection of
occupational health of health
workers and the greening of
the health sector (for example,
less toxic disinfectants,
natural ventilation)
• To support the hepatitis B
immunization campaign for
health workers (linked in
regions to vaccination week
and other vaccine-preventable
diseases)
• To reduce the exposure to
HIV and other sharps-related
infections (hepatitis B and
C) in health care workers
associated with injections
• To review and report data on
the global burden of disease
from sharps injuries to health
care workers
• First, do no harm: Introducing
auto-disable syringes and
ensuring injection safety in
immunization systems of
developing countries
• WHO best practices for injections
and related procedures toolkit
• WHO guidelines on drawing
blood: best practices in
phlebotomy
• Revised injection safety
assessment tool
• Communication strategy for
the safe and appropriate use of
injections
• The injection safety policy
planner
• Guiding principles to ensure
injection device security
• Guide to supervising injection
providers
• SIGN 2010 meeting report
• Joint WHO-ILO-UNAIDS policy
guidelines for improving health
worker access to HIV and TB
prevention, treatment, care, and
support services.
• Occupational health: A manual
for primary health care workers
• Role of the occupational health
nurse in the workplace
• Protecting health care workers
– preventing needlestick injuries
tool kit
• Joint WHO/ILO guidelines on
post-exposure prophylaxis (PEP)
to prevent HIV infection
MODULE #1
d. A Patient
Safety Culture
Program
Main HAI prevention
and control topic
and control
Main guidelines/
documents

Safe Surgery Saves Lives6
Water, sanitation,
hygiene, and health7
Reduction of complications
due to surgery, including
surgical site infections
Promotion of
environmental health in
health care settings, in
particular safe health
care waste management
• To improve the safety of surgical
care around the world by
ensuring adherence to proven
standards of care in all countries
• To contribute to the prevention
of surgical site infections
through the use of the WHO
surgical safety checklist
• To support the development
and implementation of
national policies, guidelines
on safe practices, training,
and promotion of effective
messages in a context of
healthy settings
on environmental health
standards in health care
materials for assessing the
quantities and types of waste
produced in different facilities
• To develop national health
care waste management
guidelines
• To build capacity at
national level to enhance
the way health care waste
management is dealt with in
low-income countries
• WHO surgical safety checklist
• Checklist implementation manual
• Safe health care waste
management: policy paper
• WHO core principles for achieving
safe and sustainable management
of health care waste
• Management of solid health care
waste at primary health care
centers: a decision- making guide
• Essential environmental health
standards in health care
• Natural ventilation for infection
control in health care settings
• Mercury in health care: policy
paper
MODULE #1
d. A Patient
Safety Culture
Program
Main HAI prevention
and control topic
and control
Main guidelines/
documents
1. World Health Organization (WHO). Blood Transfusion Safety. 2014. Accessed Oct 3, 2014.
http://www.who.int/bloodsafety/en/
2. World Health Organization (WHO). Clean Care is Safer Care. 2014. Accessed Oct 3, 2014.
http://www.who.int/gpsc/en/
3. World Health Organization (WHO). Infection Prevention and Control in Health Care. 2014. Accessed Oct 3, 2014.
http://www.who.int/csr/bioriskreduction/infection_control/en/index.html
4. World Health Organization (WHO). Summaries of Injection Safety Country Success Stories. 2014. Accessed Oct 3, 2014.
http://www.who.int/injection_safety/en/
5. World Health Organization (WHO). Health Workers. 2014. Accessed Oct 3, 2014.
http://www.who.int/occupational_health/topics/hcworkers/en/index.html
6. World Health Organization (WHO). Patient Safety. 2014. Accessed Oct 3, 2014.
http://www.who.int/patientsafety/safesurgery/en/index.html
7. World Health Organization (WHO). Water Supply, Sanitation and Hygiene Development. 2014. Accessed Oct 3, 2014.
http://www.who.int/water_sanitation_health/hygiene/en/
Source: Joint Commission International. Used with permission.

Adapted from: Behal R. In Youngberg BJ, Hatlie MJ, editors. The Patient Safety Handbook. London: Jones and Bartlett, 2004.
Adapted from: Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside
Out. New York: Hudson Street Press, 2010.
Source: Barbara M. Soule. Used with permission.
MODULE #1
d. A Patient
Safety Culture
A strong patient safety culture in a health care organization, or a department or service of the organization, guides the interactions
of caregivers to provide the best care, which helps to create a sense of health care as a helping profession. This then influences
individual and group attitudes, customs, and behaviors. A patient safety culture exists when there is a focused effort by the entire
staff to keep patients safe from harm. The culture affects the behavior of individuals and groups, which influences organizational
performance leading to results. Figure 1-8 and Table 1-6 highlight the characteristics of a culture of safety.
Table 1-6. Safety Culture
In a safe culture, all staff members feel responsible and accountable for actions that lead to the safety of patients; not just preventing
harm, but improving care to reduce harm to its lowest levels. Improving performance on a continual basis is critical to maintaining a
safe patient environment. Performance improvement will be discussed in detail in Module 6; however, presented here is an example
of positive improvement and change. Didier Pittet and his team from Switzerland demonstrated how to create a culture of patient
safety for promoting a new method and system change for hand hygiene by using the interventions noted in Table 1-7, below.65
Table 1-7. Hospitalwide System Change for Improved Hand Hygiene65
Senior leaders, directors, and managers in the organization are responsible for establishing a patient safety culture as a priority by
demonstrating leadership behaviors. This includes:
• Developing and presenting an organizational vision and mission
• Setting the expectations for the safest care
• Providing needed resources for care
• Serving as role models for best practices
• Supporting the desired and expected behaviors
• Motivating staff members to use best practices in their daily work
• Providing incentives and rewards for desired behaviors
Figure 1-8. Culture of Safety
Infection Processes
and Outcomes
Culture
Individual and
Collective Behavior
Organizational
Performance
1. A culture where all workers (including front-line staff, physicians, and administrators) accept responsibility for the safety
of themselves, their coworkers, patients, and visitors.
2. A culture that prioritizes safety above financial and operational goals.
3. A culture that encourages and rewards the identification, communication and resolution of safety issues.
4. A culture that provides for organizational learning from accidents.
5. A culture that provides appropriate resources, structure, and accountability to maintain effective safety systems
• System change (from soap and water to alcohol-based hand rubs)
• Education of health care workers (all staff members and all shifts)
• Monitoring and feedback of performance (compliance)
• Reminders in the work place (changing posters)
• Administrative support (personnel for maintaining records)
• Leadership and culture change (leadership commitment)

MODULE #1
d. A Patient
Safety Culture
Without leadership commitment to these actions, it is hard to create and maintain a culture of patient safety. Table 1-8, below,
contains key elements of a patient safety culture that can be applied in any country, region, health care setting, department, or
service, with examples applicable to infection prevention. This same information is presented in Tool 1-2 for use in all clinical and
support services. The culture of patient safety is discussed further in Modules 2-6.
Communication
Collaboration and Teamwork
Organizational Learning
No Blame-Just Culture
Evidence-Based Practices
Systems Thinking
Measurement and Data
Open, honest, sharing data, feedback,
non-punitive reporting system for errors
Working together to maximize the
talents and skills of all team members
Open minds to new information and
new methods of providing care, or
performing processes. Learning from
errors to prevent them in the future.
Look at the system, encourage critical
analysis of errors, avoid blaming
individuals for system errors
Leaders must choose either blame and
secrecy, or openness, forgiveness, and
safety. Blame does not work
Adopting or adapting best practices and
integrating into the work environment
Addressing problems or improvements
by looking at all interconnected
components, including people,
processes, equipment, environmental
issues, information
To identify gaps in best practices and
quantify them; data collection and
analysis
Sending surveillance reports, making
rounds in the service or unit, analyzing
errors and reporting them
Teams working on the clinical unit and
in the OT to ensure that the patient is
prepared correctly for surgery
Using new technology to ensure
appropriate sterilization of instruments
Nonpunitive response to an infection
that is not preventable Honest sharing
of breaks in technique by staff in the OT
that may have contributed to infection
risk for patients; examining the OT
systems that supported the technique
errors, for example, not covering hair
when operating; not following policy
for PPE
Review of newly published guidelines
from respected sources, for example,
WHO, CDC, Ministries of Health,
and reflecting guideline content in
organizational or departmental policies
and procedures
Inadequate space in the Sterile
Processing areas to avoid contact
between clean and dirty instruments.
Investigating the environmental
constraints, equipment flow, staff
training, other parts of the system
Establishing performance indicators to
monitor key processes, for example in
SterileProcessingortheOT,Emergency,or
other areas, and systematically collecting
and analyzing data about these processes
to determine improvement opportunities
Patient Safety Culture Definition Example for Infection Prevention
Table 1-8. Key Elements of Patient Safety Culture

Human Factors
Zero Tolerance
Identify points of convergence
between the human behavior and
work environment and technology,
and modify the components to
minimize or eliminate errors
Expect all staff members to use best
practices when known
Identifying opportunities to support
staff in best practices, for example,
appropriate trays for immediate–use
sterilization, alert systems when
machines not working properly
When a new evidence-based policy is
initiated, expect all staffers to comply
with the policy, for example, not
wearing surgical scrub wear out of the
hospital; full preoperative scrub
Patient Safety Culture Definition Example for Infection Prevention
MODULE #1
d. A Patient
Safety Culture

MODULE #1
e. Evidence-Based
Practice
To effectively minimize infections in patients, it is necessary to develop direct patient care practices and support service practices
based on the most current evidence that demonstrates efficiency, efficacy, and safety. This topic is discussed below, and other sections
of the toolkit describe in more detail these practices for the operating theater (OT) and the central sterile supply department (CSSD).
Evidence-based guidelines are created from valid scientific studies that examine specific practices to determine if they affect care
outcomes. Many guidelines of evidence-based practices are available for use in clinical and support service practices. The guidelines
may address direct care issues, such as prevention of device-associated infections and procedural risks, hand hygiene or practices
related to the environment, such as cleaning of isolation rooms or isolation practices,66
disinfection and sterilization techniques used
in services such as the OT,67
CSSD, and environmental services.68
Unfortunately, evidence-based practices are not always implemented in organizations or integrated into patient care or support
service procedures. Lack of compliance with hand hygiene is a classic example.69,70
In spite of staff education about hand hygiene and
information about the value of the practice and an organizational policy clearly supportive of adherence to hand hygiene, compliance
may be less than optimal. This challenge applies to many guidelines. For all guidelines, lack of implementation may result from:
• The organization’s inability to access the most current information
• Lack of resources to carry out and maintain the guideline
• A deficiency in skill to implement and embed new information into daily work
• Lack of procedures to sustain best practices
• Barriers to implementation resulting from the culture and values of the organization and its leaders
Implementing evidence-based recommendations is an ongoing challenge for hospitals and a risk point for patients. Many guidelines
exist that inform best practices infection prevention activities. A few are listed in Table 1-9, below.
Table 1-9. Evidence-Based Guideline Resources
• World Health Organization (http://www.who.int)
• Centers for Disease Control and Prevention (http://www.cdc.gov)
• Institute for Healthcare Improvement (http://www.IHI.org)
• International Federation of Infection Control (http://www.theific.org)
• Singapore Infection Control (http://www.icas.org.sg/gudeline.html)
• National Guideline Clearinghouse (http://www.ngc.gov)
• National Institute for Health and Care Excellence (NICE) UK (http://www.nice.org.uk)
• Association of Perioperative Registered Nurses (AORN) (http://www.aorn.org/Books_and_Publications/Perioperative_
Standards_and_Recommended_Practices/Perioperative_Standards_and_Recommended_Practices.aspx)
• Agency for Healthcare Research and Quality (AHRQ) (http://www.ahcpr.gov/clinic/epcix.htm)
• Evidence-Based Practice Centers (http://www.ahrq.gov/clinic/epc)
• National Resource for Infection Control (http://www.nric.org.uk)
• Scottish Intercollegiate Guidelines Network (SIGN) (http://www.sign.ac.uk)
• The-ASEAN-Guidelines-for-Disinfection-and-Sterilisation-of-Instruments-in-Health-Care-Facilities.pdf APSIC (http://
apsic.info/documents)
• SHEA-Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals (http://www.
shea-online.org/Topics/CompendiumofStrategiestoPreventHAIs.aspx)
• Association for Professionals in Infection Control and Epidemiology (APIC) Implementation Guides (http://www.apic.org/
Professional-Practice/Implementation-guides)
• Hospital Infection Society India (http://hisindia.org)
• Infection Prevention and Control Nurses New Zealand (http://www.infectioncontrol.co.nz/home)

MODULE #1
e. Evidence-Based
Practice
Each facility must have a process in place to stay abreast of current science, the newest recommendations, and the obstacles to
implementing evidence-based practice. One critical issue is identifying priorities so projects can be aligned with available resources
and financial restraints. Once those factors are understood, the organization can more effectively integrate and sustain practices that
will enhance patient safety and reduce infection risk.
Effective implementation of guidelines into routine work continues to be a major challenge. Even the best of new guidelines and
evidence-based position papers are not readily adopted. What is clear from research is that simultaneous multiple implementation
strategies are more likely to result in successful implementation than a single approach.71
In a synthesis of 44 systematic reviews and
observations of professional behavior change, the following observations emerged (see Table 1-10, below).
Table 1-10. Observations of Methods to Create Professional Behavior Change
Designing and embedding evidence-based guidelines into daily work processes requires the involvement of a multidisciplinary team,
including nurses, physicians, quality improvement and patient safety professionals, IPC professionals, and information technology.
Specialists from the departments or services involved, such as from the OT or CSSD service, should be included when the issue relates
to their area. Senior leaders may also participate. The team can use various systematic methods to analyze and create improvement:
• Plan Do Study Act (PDSA) or Plan Do Check Act (PDCA)
• The 4 Es: Engage, Educate, Execute, Evaluate
• Define, Measure Analyze, Improve and Control (DMAIC)
• Six Sigma
• Lean Six Sigma
• Robust Process Improvement
Other performance improvement methods can also employ general “change management” concepts to facilitate such changes. The
methods for improving quality and performance are discussed in each module and presented in detail in Module 6. Examples of potential
change projects in the OT and CSSD are listed in Table 1-11, below.
Table 1-11. Potential Performance Improvement Projects for the OT and CSSD72-75
Methods Less Likely to Succeed
Operating Theater Change Projects
Methods More Likely To Succeed
CSSD Change Projects
Passive dissemination of information—generally ineffective
Clinical Workflow During Surgery
Double Gloving for Surgical Procedures
Sharps Management in the OT
OT Design for Patient Safety
Timing of Room Turnover
Timing of Preoperative Antibiotic Administration
Methods for Minimally Invasive Procedures
Dissemination of educational materials and didactic
educational presentations—usually ineffective
Audits, feedback, local consensus process, and use of local
opinion leaders—variable results
Reminders, interactive educational sessions— generally effective
Efficient Flow of Instruments
Managing Endoscopy Equipment
Appropriate Cleaning of Instruments
Cleaning and Sterilization or High Level Disinfection of Anesthesia Instruments
Compliance with Personal Protective Equipment (PPE)
Process for Notification When Biological Monitor Fails
Process for Creutzfeldt-Jakob Disease Prion Contamination of Instruments
Interventions based on knowledge of barriers to
implementation—more likely to succeed
Multifaceted interventions that focus on barriers to
implementation—more likely to succeed
Adapted from: Gross PA. Implementing evidence-based recommendations for health care: a roundtable comparing European and American experiences. Jt
Comm J Qual Improv. 2000 Sep;26(9):547-53. Used with permission.

MODULE #1
e. Evidence-Based
Practice
Organizations benefit from a systematic approach to working through challenges for implementing evidence-based practices. Table
1-12, below, highlights challenges and potential Solutions for achieving evidence-based best practices. The table is also available as
Tool 1-3.
Table 1-12. Checklist of Challenges and Potential Solutions for Achieving Evidence-Based Best Practices
The Challenge for Implementing
Evidence-Based Procedures
Potential Solution(s) to the Challenge
Action(s) Taken to Achieve Success in
Overcoming the Challenge
Organization Complete This Section
Absence of a Strategic Plan for
the Department/Service
Lack of Support from Leadership
Lack of Adequate Staffing
Lack of Time to Attend to the Matter
Lack of Knowledge About the Topic
• Perform a Risk Assessment to determine
risk points for unsafe care or need for
improvement to evidence-based practice.
(See Tool 1-7, Risk Assessment Primer.)
• Identify the best practices to be achieved.
• Develop a list of priorities for the department.
• Address the highest priority first, then others.
• Develop a compelling case for working
toward best practice based on patient safety,
cost, hospital mission, and objectives.
• Find a champion or mentor who is respected
by leadership to work with you.
• Present the case to leaders.
• State clearly what you need from leadership and
what you will provide, and the benefits to patients.
• Collaborate with and engage other
department staff(s) to work on the issue.
• Align the work with organization mission, and
leadership goals and objectives.
• Divide the work into easy to accomplish parts.
• Share responsibilities with various health
care disciplines if possible.
• Assign work to different staffs.
• Develop a compelling business case for
additional staff. See Module 6.
• Divide work into small sections.
• Develop project timelines and project due dates.
• Establish realistic target goals and dates.
• Gather information including guidelines,
recommendations, literature.
• Plan and present an educational program
about the topic and the objective of change.
• Collaborate with the expert in the
departments involved and the infection
preventionist.

The Challenge for Implementing
Evidence-Based Procedures
Potential Solution(s) to the Challenge
Action(s) Taken to Achieve Success in
Overcoming the Challenge
Organization Complete This Section
Lack of Financial Clarity
Continual Change in Staff
• Work with the financial department; find a
mentor in the department.
• Identify costs and resources needed to
implement evidence-based practice.
• Identify low, intermediate and high priorities
to accomplish goals.
• Develop a training program for all new staff
to teach or reinforce best practices.
• Consider certification in practice before
independent work.
• Establish a training budget.
• Embed the best practice into work through
clear policy and expected behaviors.
• Explore training assistance from vendors for
equipment, devices, and supplies.
Successfully implementing evidence-based preventive measures and embedding them into daily work processes requires
understanding of the complex issues within an organization and may vary from one country or one facility to another.71,76,77
Figure
1-9, below, illustrates a model used in IPC for translating theory to practice, and Table 1-12, on the next page, lists actions that may
be helpful to successfully translating best practices from theory to implementation and to embedding these practices into normal
work routines. The effectiveness of implementation strategies to translate evidence-based guidance into practical work routines is
challenging but critical to reducing infections and improving patient safety. Also see Tool 1-4.
Figure 1-9. A model used in IPC for translating theory to practice
MODULE #1
e. Evidence-Based
Practice
Source: Saint S, Howell J, Krein SL. Implementation science: how to jump‐start infection prevention. Infect Control Hosp Epidemiol. 2010 Nov;31
Suppl 1:S14-7. Used with permission.
Characteristics of the
infection prevention practice
Adoption Decision Implementation
Healthcare-Associated
Infection Rate
Environmental context
Organizational
Characteristics

Sidebar 1-3. Guidelines for Translating Best Practices from Theory to Practice
1. Understand the culture of the organization and leaders with respect to change.
2. Delineate the obstacles in the face of implementation.
3. Form a multidisciplinary team to get input from users of the process.
4. Describe the current state of the event and the desired state.
5. Use change management and performance improvement methods for the process.
6. Empower health care personnel to speak up.
7. Start with a small change and move to a larger scale.
8. Provide communication and feedback of data to health care personnel.
9. Use checklists and reminders to reinforce desired behaviors.
MODULE #1
e. Evidence-Based
Practice
Adapted from: Al-Tawfig JA, Memish ZA. Future issues in infection control. In Soule B, Memish Z, Malani P, editors: Best Practices in Infection Prevention
and Control: An International Perspective, 2nd ed. Oak Brook, IL: Joint Commission International, 2012, 33. Used with permission.
Source: Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis.
2006 Aug 16;6:130.
In health care settings worldwide, patients experience their care and caregivers and support staff perform their work, not in isolation,
but within the environment of their organization. There is increasing evidence that the contaminated environment can be a factor
in transmitting pathogens that can cause HAIs78
and that disinfection and sterilization processes may not prevent infections if not
performed thoroughly and correctly.
The approach to reducing environmental risk for infections is similar in all countries and regions. Hospital staff must maintain a clean
environment to minimize microorganisms that can be transferred and spread to patients or staff members. This is accomplished
by sanitizing or cleaning to reduce microorganisms on surfaces, decontaminating or disinfecting to remove blood and body fluids
and organisms, and disinfecting instruments. Each health care facility must establish and write its own policies for cleaning and
disinfecting and ensure that environmental services staff performing these processes are well-trained, and that the chemical agents
and the pH of the water or water temperature (for example, hot/superheated water) are being used correctly, are compatible, and are
effective. Personnel who clean and disinfect equipment and the environment must wear appropriate personal protective equipment
(PPE) for their safety.79
The great concern about the environment comes from the close and constant interaction between the inanimate environment and
people. The environment serves as a reservoir that contains a large number of microorganisms that can often disperse efficiently,
proliferate in moist environments and organic material, and even survive on dry surfaces. When cleaning, particularly of patient care
rooms, is not thorough, organisms will remain on surfaces, and subsequent patients admitted to the room are at risk for acquiring
infections.78
Microorganisms can change their metabolism to meet their environmental needs, making them more or less pathogenic
to humans. Therefore, routine cleaning is necessary on an ongoing basis to keep the environment clean and free from dust and soil
where organisms may reside.79
Figure 1-10, below, illustrates how organisms from the environment are transferred to the hands of health care workers and from
there to patients.80
Figure 1-10. How organisms transfer in the care environment
ENVIRONMENT OF CARE
CLEANING AND DISINFECTING THE PHYSICAL ENVIRONMENT
Contaminated
inanimate surface
Hands of healthcare
worker
Susceptible Patient
direct transmission
Compliance in hand hygiene: - 50%

Source: Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis.
2006 Aug 16;6:130. 2006 Aug 16;6:130.
MODULE #1
e. Evidence-Based
Practice
Table 1-13, below, illustrates the amount of time various viruses can live on dry, inanimate surfaces. This information is useful for
thinking about cleaning regimens and for teaching environmental services staff about cleaning and direct care providers about
hand hygiene.80
Table 1-13. Persistence of Clinically Relevant Viruses on Dry Inanimate Surfaces
Type of virus Duration of Persistence (range) Source
Adenovirus
Astrovirus
Coronavirus
SARS associated virus
Coxsackie virus
Cytomegalovirus
Echovirus
HAV
HBV
HIV
Herpes simplex virus, type 1 and 2
Influenza virus
Norovirusandfelinecalicivirus(FCV)
Papillomavirus 16
Papovavirus
Parvovirus
Poliovirus type 1
Poliovirus type 2
Pseudorabies virus
Respiratory syncytial virus
Rhinovirus
Rotavirus
Vacciniavirus
7 days – 3 months
7 – 90 days
3 hours
72 – 96 hours
> 2 weeks
8 hours
7 days
2 hours – 60 days
> 1 week
> 7 days
4.5 hours – 8 weeks
1 – 2 days
8 hours – 7 days
> 7 days
8 days
> 1 year
4 hours – < 8 days
1 day – 8 weeks
≥ 7 days
up to 6 hours
2 hours – 7 days
6 – 60 days
3 weeks – > 20 weeks
[32, 34, 38–41, 111]
[38]
[112, 113]
[114]
[34, 111]
[115]
[114]
[35, 38, 41]
[116]
[117–119]
[34, 111, 118, 120]
[39, 43, 121, 122]
[42, 45]
[123]
[118]
[118]
[35, 118]
[34, 38, 111]
[124]
[44]
[33, 125]
[36 – 38, 41]
[34, 126]

MODULE #1
e. Evidence-Based
Practice
Infection risks in the environment may evolve from lack of adequate cleaning and disinfecting of the environment, particularly
surfaces,81
and from the incorrect management of instruments and devices used for patient care. A 2008 multihospital study by
Carling used a novel fluorescent targeting method to evaluate the thoroughness of cleaning. The results showed that from more
than 20,000 surfaces tested, only 48% were cleaned. as the study began. The thoroughness of cleaning appeared to correlate with the
expenditure for environmental service personnel. After interventions were implemented and performance feedback was provided to
the environmental services staff, cleaning on environmental surfaces increased to 77%.82
In a related study Carling and his team evaluated cleaning in ICUs in 16 hospitals. Target surfaces were marked with a clear solution
that would show up and would fluoresce when exposed to UV light if the surface was not well-cleaned. Interestingly high rates of
cleaning (>80%) were found for toilet seats, sinks and tray tables. There was a low rate of cleaning (<30%) of bedpans, the toilet area
hand hold, doorknobs, and light switches, all of which are frequently touched by caregivers and families. The methodology presented
in these studies may help organizations improve environmental cleaning with little expense. 83
Another study of environmental contamination captured the percent of environmental cultures obtained that were positive for MRSA.
This study found that the floor and patient bed linens were the most highly contaminated areas (but least likely to be involved in
transmission of organisms to patients), and that the blood pressure cuff, bed side rails, and door handle showed lower contamination
levels.84
Studies such as these can guide environmental cleaning practices.
The education of environmental services staff is essential for successful cleaning of the environment. These staff members need
to know about the techniques they are to use, the agents, and how to measure or dilute and use them. They also need to know and
take precautions for their own safety with PPE and careful management of waste that may be hazardous. Module 5 presents detailed
information about a safe environment.
Sterilizing equipment such as surgical instruments, packs, and other supplies is a key infection prevention strategy in any health
care organization and an important environment of care issue. Sterilization may be performed in the facility in a centralized or
decentralized system, or by a contracted agency. The process for receiving, washing, sterilizing, packaging and storing instruments
and other equipment should follow established standards, such as moving the instruments from dirty to clean without cross-
contamination, having the appropriate washing and sterilizing equipment and technology, correct ventilation and air pressure, and
storage areas that are restricted, have positive air pressure, and have a system to identify contaminated or outdated supplies. Tested
guidelines are available, and these are discussed in greater detail in Modules 3, 4, and 5.
The management of medical waste is a challenge worldwide. Great quantities of waste are generated from the delivery of health
care, and a significant part is considered medical infectious waste, which poses some risk to handlers and others. Below is a list of
the major sources of health care waste:85
• Hospitals and other health care establishments
• Laboratories and research centers
• Mortuary and autopsy centers
• Animal research and testing laboratories
• Blood banks and collection services
• Nursing homes for the elderly
STERILIZATION
MEDICAL WASTE

MODULE #1
e. Evidence-Based
Practice
Various countries have performed detailed surveys of hospitals, clinical units within hospitals, laboratories, and other settings to
quantify the types and amounts of waste and handling practices.86 -90
Some studies found that barriers to careful management of
medical wastes included the following:
• Lack of guidelines
• Lack of education and training for staff
• Ineffective segregation at the source
• Inappropriate collection methods
• Unsafe storage
• Poor control of waste disposal
• Lack of PPE for staff
• Financial and administrative issues
Other waste studies looked at different aspects of hospital wastes. One study identified the amount of multidrug resistance in bacteria
from liquid wastes from a hospital in Nepal.91
A study in Iran looked at performance improvement using a quality management
approach to try to reduce the amount of infectious waste that was generated.92,93
A qualitative study from Iran revealed that managerial
weakness related to lack of education, organizational resources, and supervision were key factors.94
Various countries may define
infectious waste differently, but in general it includes:
• Blood and body fluids from routine patient care activities, such as contaminated dressings, surgical drapes, and sponges
• Any contaminated items that would release blood or other potentially infectious materials as a liquid if compressed, or items
caked with dried blood or other potentially hazardous materials that could release these materials during handling
• Sharps such as lancets, needles, or glass contaminated with blood or body fluids, and phlebotomy equipment
• Isolation waste from persons with highly infectious diseases, such as viral hemorrhagic fevers and other infectious materials
• Pathological or microbiological specimens containing blood, or other potentially infectious materials
Waste management is also discussed in Module 5.
Injections are the most common health care procedure in the world, and many millions of injections are administered each year
in developed, developing and transitional countries.95
Most needles and syringes end up as infectious waste, and they pose risks
associated with waste disposal that can be very serious. More than 90% of injections are administered for therapy and the remaining
5-10% for prevention, such as immunizations. Unfortunately, most therapeutic injections in developing and transitional countries are
unnecessary,95
and many injections are unsafe. The issue of reusing disposable, one-time use syringes and needles for injections is
a problem in many countries, particularly certain African, Asian, and Central and Eastern European countries . The, the reuse places
the patient or health care worker at risk for infection, disability or even death.85
The WHO estimated that in 2000, persons injected with contaminated syringes caused about 21 million hepatitis B virus (HBV)
infections, two million hepatitis C virus infections, and 260,000 human immunodeficiency virus (HIV) infections worldwide.85
If the
syringes had been disposed of in a safe manner, many of these infections would have been avoided.
INJECTION SAFETY

MODULE #1
e. Evidence-Based
Practice
Each health care facility must have a clear policy on the safe handling of medical waste from the point of generation to final disposal,
also termed “from cradle to grave.” The process must include the steps addressing how waste is handled and segregated at the
bedside or in support departments, how it is contained, transported and stored within the facility, and how it is disposed of either in
the facility with methods such as sterilization or incineration, or outside the facility in landfill. The WHO has developed an eight-step
process outlining medical waste management that can be used as a tool to help facilities examine their current process to determine
if improvement is needed. The process also provides many tools to assist organizations with waste management. See discussion and
the tool in Module 5 and at http://www.who.int/mediacentre/factsheets/fs253/en/.
Everyone who handles sharps is at risk of being stuck with a contaminated needle or cut from a used scalpel. Specific procedures
must be in place to prevent these injuries. As described in Modules 3 and 5, there are many creative ways to reduce risk to personnel.
Waste management workers are particularly at risk for sharps injuries when safe disposal processes are not followed or when
manual sorting is the process. Appropriate disposal of needles and syringes, and eliminating reuse are key to preventing these
infections. The WHO has published Guiding Principles to Ensure Injection Device Safety97
and Best Practices for Injections and Related
Procedures Toolkit as well as other helpful documents.98
Sharps management is also discussed in Modules 5 and 6.
WASTE MANAGEMENT
• No loose disposable injection equipment outside of packaging in the facility
• No loose disposable phlebotomy equipment outside of packaging in the facility
• No loose disposable intravenous equipment outside of packaging in the facility
• No loose scalpels during surgical or other procedures
• No evidence of re-sterilization of disposable injection equipment
• No used sharps outside of safe containers specific for sharps
• No multidose vials with needles left in the diaphragm
• Running water and soap for cleansing hands before using sharps
• Alcohol-based hand rub for cleansing hand before using sharps
Adapted from: World Health Organization (WHO). Revised Injection Safety Assessment Tool (Tool C – Revised). 2008. Accessed Oct 3, 2014.
http://www.who.int/injection_safety/Injection_safety_final-web.pdf
See Table 1-14, below, for tips for safe management of sharps to prevent sharps injuries and infection risk. 96
Table 1-14. Tips for Safe Management of Sharps to Prevent Sharps Injuries and Infection Risk

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