A Case Study of Organizational Risk on Hospital-Acquired Infections

Shelley Johnson


Nurs Econ. 2018;36(3):128-135. 

In This Article

Abstract and Introduction


ON ANY GIVEN DAY, 1 of every 25 patients hospitalized in the United States will have a hospital-acquired infection (HAI) (Centers for Disease Control and Prevention [CDC], 2018a). These infections are a patient safety risk and add to the cost of health care. They are also mostly preventable. While this number of HAIs has been declining since 2009, there is still work to be done to achieve a goal of eliminating HAIs (CDC, 2018a; Institute for Healthcare Improvement [IHI], 2018a).

The current rate of HAIs in a community hospital and healthcare organization in Northern California places it at high risk for patient safety, ethical, regulatory, financial, and legal exposure. HAIs causing the most concern are catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), and Clostridium difficile (C. diff) infections. Numbers and rates of HAIs were the same or increased in 2016 compared to 2015. These HAIs are above the CDC's National Healthcare Safety Network (HNSH) benchmarks. The estimated additional cost of care related to CAUTIs, CLABSIs, and C. diff in the organization totaled $1,384,000 in 2016, down slightly from $1,440,352 in 2015 (see Table 1). The organization's goal was to decrease each of these HAIs by at least 20% in 1 year by engaging an interprofessional workgroup of frontline staff members to focus on improving processes and practices related to HAIs. This article describes the efforts employed by the workgroup the first year.