Ideas That Work: Root Cause Analysis

On those rare occasions when a patient contracts a surgical site infection, we want to preserve as much evidence in the case as possible so we'll be better able to find the source of the infection and take corrective action. For us, it's the "Patient Peel Pack Log," a binder where we place the peel pack and the autoclave indicator tape with the load number of the instruments used on a specific patient, along with the time and date. We write the names of the instruments on the sterilization labels and place them next to the patient information sticker in the log. We can easily go back when we're doing a root cause analysis and figure out if there was a problem with the sterilization of the instruments.