Sepsis: Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of hospital associated Sepsis, clinical and system reviews should be conducted to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

1. Measure and monitor the types and frequency of these occurrences.
2. Use appropriate analytical methods to understand the contributing factors.
3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resources Introduction. 

If your review reveals that your cases of Sepsis are linked to specific processes or procedures, you may find these resources helpful:

• BC Patient Safety and Quality Council https://bcpsqc.ca/
• BC Patient Safety & Quality Council. BC Sepsis Network. BC Patient Safety & Quality Council. https://bcpsqc.ca/improve-care/bc-sepsis-network/
• Canadian Patient Safety Institute (CPSI) https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Improvement-Resources/Pages/default.aspx
• Hospital Harm Improvement Resource – Infections due to C.diff, MRSA, VRE
• Hospital Harm Improvement Resource – Pneumonia
• Hospital Harm Improvement Resource – Post-Procedure Infections
• Hospital Harm Improvement Resource – UTI.
• Centers for Disease Control and Prevention www.cdc.gov
• Centers for Disease Control and Prevention. Sepsis: Clinical Information. Clinical Resources. Published December 7, 2020. Accessed March 2021. https://www.cdc.gov/sepsis/clinicaltools/index.html
• Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control Hospital Epidemiology. 2010;31(4):319-326. http://www.cdc.gov/hicpac/pdf/cauti/cautiguideline2009final.pdf
• Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention. Morbidity and Mortality Weekly Report. 2016;65(33):864-869. http://dx.doi.org/10.15585/mmwr.mm6533e1
• Tumpey A. Empowering Nurses for Early Sepsis Recognition; 2016. Accessed March 2021. https://www.youtube.com/watch?v=s687VMj6iwo
• Tumpey A. Sepsis Standard Work: Improving Compliance with Early Recognition and Management of Perinatal Sepsis; 2017. https://www.youtube.com/watch?v=BUuFfwsj1W4
• Tumpey A. Advances in Sepsis: Protecting Patients Throughout the Lifespan; 2016. Accessed March 23, 2021. https://www.youtube.com/watch?v=EASYi4-_bv4
• Global Sepsis Alliance www.global-sepsis-alliance.org
• Infection Prevention and Control Canada www.ipac-canada.org
• Society of Critical Care Medicine https://www.sccm.org
• Surviving Sepsis Campaign https://www.sccm.org/SurvivingSepsisCampaign/Home
• Guidelines and Bundles
• Covid-19 Guideline https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/COVID-19
• Adult Patients https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients
• Pediatric Patients https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Pediatric-Patients