scholarly journals 774. Outbreak of Central-Line-Associated Bloodstream Infections (CLABSI) amid the COVID-19 Pandemic Associated with Changes in Central Line Dressing Care Accompanying Changes in Nursing Education, Nursing Documentation, and Dressing Supply Kits

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S484-S484
Author(s):  
Ahad Azeem ◽  
Irene L Newquist ◽  
Lesley L Royal ◽  
Kimberly S Hemrick ◽  
Zachary A Creech ◽  
...  
Keyword(s):  
Nursing Education ◽  
Medical Center ◽  
Panel Member ◽  
Central Line ◽  
Swiss Cheese ◽  
Nursing Documentation ◽  
Competency Training ◽  
First Case ◽  
Swiss Cheese Model ◽  
Cheese Model

Abstract Background National Healthcare Safety Network (NHSN) data have revealed an increase in CLABSI associated with the COVID-19 pandemic, but data on factors mediating the increase are limited. Our hospital had been free of CLABSI for 18 months, but we encountered an outbreak of 7 CLABSI over a 5-month period beginning in November 2020. This led to an investigation that revealed that some underlying issues were related to COVID-19. Methods Infection prevention staff at Omaha’s Veterans Affairs Medical Center interviewed hospital staff and performed a retrospective chart review of patients with CLABSI (based on the NHSN definition) amid the COVID-19 pandemic. Results The first case of CLABSI in the outbreak was detected in November 2020. Prior to that, there was no case of CLABSI since April 2019, as shown in the graph. Each case of CLABSI was associated with a different microorganism. Further investigation revealed deviations from our usual practices in central line dressing care. Our response to COVID-19 had included alterations in periodic competency training (including dressing care) for nursing staff as well as the rapid introduction of streamlined inpatient nursing documentation. Previously, dressing kits included chlorhexidine-impregnated dressings; in November, a kit without these dressings was introduced. A weekly audit of dressing care was begun in March 2021. No CLABSI was identified in April 2021. Types of Microorganisms identified Different types of microorganisms isolated during the CLABSI outbreak each month. The trend of CLABSI in VA Nebraska-Western Iowa Health Care System Conclusion We encountered a CLABSI outbreak associated with deviations from usual central line dressing care. Using the concept of the Swiss cheese model of error prevention, we recognized alterations in three barriers: competency training; thorough documentation; and complete supply kits. The first two of these factors were directly related to our COVID-19 response. Our findings illustrate the relevance of the Swiss cheese model for maintaining a safe healthcare environment. Disclosures Marvin J. Bittner, MD, Merck (Advisor or Review Panel member)Sanofi Pasteur (Speaker's Bureau)

Application of Fault Tree Analysis and Swiss Cheese Model to the Overspeed Derailment of Puyuma Train in Yilan, Taiwan

2020 ◽  
Vol 2674 (5) ◽  
pp. 33-46
Author(s):  
Jyh-Cherng Jong ◽  
Yung-Cheng (Rex) Lai ◽  
Cheng-Chung Young ◽  
Yu-Fu Chen
Keyword(s):  
Process Analysis ◽  
Fault Tree ◽  
Fault Tree Analysis ◽  
Swiss Cheese ◽  
Contributing Factors ◽  
Tree Analysis ◽  
Train Control ◽  
Swiss Cheese Model ◽  
Express Train ◽  
Cheese Model

On October 21, 2018, a Puyuma express train went overspeed through a sharp curve and derailed in Yilan, Taiwan. This accident resulted in 18 fatalities and 267 injuries. Although such accidents occur once in a while worldwide, this case of an overspeed derailment from a train-set equipped with an automatic train protection (ATP) system (similar to the function of Positive Train Control (PTC) in the U.S.) is rare. A temporary investigation team was appointed by the Executive Yuan, the highest administrative organ in Taiwan, and the investigation was completed within 2 months. This paper presents the process, analysis, findings, and recommendations from the accident investigation. The accident was first analyzed using fault tree analysis to identify potential causes and contributing factors of this derailment. The results were then categorized into layers of defenses by using a Swiss cheese model. We further extended the original Swiss cheese model to a “time-dependent Swiss cheese model” to demonstrate how the barriers were penetrated at different times by incorporating the timestamps of important events. Another modified Swiss cheese model called “causal relationship Swiss cheese model” was presented to further demonstrate the causal relationships. With the proposed process and models, the immediate causes and contributing factors were quickly identified and presented in a way that could be easily understood by the general public. The results showed that the ATP system (or the PTC) cannot guarantee 100% safety. A review of the safety culture and corresponding procedures is important to ensure the safety of railway operations.

CRITICAL EXPONENTS OF ELASTICITY IN A CONTINUUM PERCOLATION SYSTEM (INVERSE SWISS-CHEESE MODEL)

Fractals ◽  
1993 ◽  
Vol 01 (04) ◽  
pp. 904-907
Author(s):  
K. MARUYAMA ◽  
K. OKUMURA ◽  
H. YAMAUCHI ◽  
S. MIYAZIMA
Keyword(s):  
Elastic Constant ◽  
Electric Conductivity ◽  
Critical Exponents ◽  
Experimental Studies ◽  
Continuum Percolation ◽  
Swiss Cheese ◽  
Swiss Cheese Model ◽  
Percolation Problem ◽  
Cheese Model ◽  
Model Continuum

Critical exponents of elastic constant of Inverse Swiss-cheese model (Continuum percolation problem) is experimentally investigated following our previous experimental studies on electric conductivity and permeability in a continuum percolation system.

scholarly journals Analyzing the cause of human electrical accidents using Swiss Cheese model

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Beena Puthillath ◽  
Bhasi Marath ◽  
Babu Chembakthuparambil Ayappan
Keyword(s):  
Electrical Energy ◽  
Electrical Safety ◽  
Swiss Cheese ◽  
Content Type ◽  
Safety Issues ◽  
Swiss Cheese Model ◽  
Utility Companies ◽  
Accident Data ◽  
The Difference ◽  
Cheese Model

Purpose This study aims to explore the factors influencing electrical accidents. Here, the authors aim to understand and model the causes of electrical accidents at multiple levels. Design/methodology/approach In the study, the authors have tried to put causes of accidents in the electricity distribution segment, in the framework of the Swiss Cheese model. Delphi kind of expert survey was conducted to find the Cheese Slice (level) and the causes (holes) for electrical accidents. Inputs from a hundred experts having more than five years of experience in electrical utility companies have been used to find Cheese Slice and holes, to explain the occurrence of an electrical accident. Findings Effective training for safe work practices, safe knowledge and closer supervision would go a long way to plug the holes in the Cheese Slice in human factors. The difference in perception of managers, supervisors and workers on the importance of various causes of electrical accidents are also presented and discussed. Research limitations/implications This research is based on expert opinion and survey where respondent perception is reported. Actual accident data has not been used here. Practical implications The holes or causes of accidents at different levels (Cheese Slice) have been identified for plugging or removal for better safety. Social implications Electrical energy is widely used, and therefore, electrical safety is a social concern and also improving it is a social need. Originality/value The study contributes to electrical safety issues in the electrical utility sector.

scholarly journals Good and bad reasons: The Swiss cheese model and its critics

2020 ◽  
Vol 126 ◽  
pp. 104660 ◽  
Author(s):  
Justin Larouzee ◽  
Jean-Christophe Le Coze
Keyword(s):  
Swiss Cheese ◽  
Swiss Cheese Model ◽  
Cheese Model
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