Effective and Efficient Infection Prevention Violation Reporting

Background: Large and complex healthcare institutions with a hierarchical
organizational structure may have inherent barriers that interfere with
effective communication and the reporting of infection prevention violations.
Objective: Characterize infection prevention violations documented through an
institution-wide, anonymous, non-punitive reporting system.
Methods: Infection prevention violations are recorded on a standardized form. 
Reports may be submitted by all personnel to the Department of Healthcare
Epidemiology through verbal/telephone routes, hard copy via the institutional
mail, or completion of an online form.  Once received, the violations are
analyzed and appropriate response is instituted.  Although the identity of the
person reporting the violation is recorded, this information is not revealed in
any communication to the person committing the violation.   
Results: 541 infection prevention violations were reported between the years of
2000 and 2008 (range 32 to 95 per year).  Comparatively, 1220 infection
prevention violations were reported between the years of 1990 and 1999, (range
62 to 200 per year).  Infection prevention violation reports are divided into
specific categories.  The categories are Isolation (28%), Waste Disposal (8%),
Standard Precautions (11 %), Improper Sterile/ Aseptic Technique (13%), Used
Sharps Disposal (8%), Tube System Spills/Specimen Handling (15%) and
Miscellaneous (17%). A yearly summary and analysis of violations are submitted
to the Infection Control Committee and published in the Departmental Annual
Report.  Identification of infection prevention infractions have led to
performance improvement activities such as product evaluation and introduction,
development/enhancement of instructional signage, adjustments in
procedure/practices/policies and methods to routinely review practices.
Conclusions: Infection prevention violation reporting is a valuable tool for
identifying breakdown in procedures and fostering effective communication. In
addition, violation reporting empowers the healthcare worker to be directly
involved with the challenges of infection prevention and promotes their
involvement in positive solutions.