Healthcare Associated Infections

Service: Risk Management
Subject: Care
Setting: Infection

Healthcare associated infections (HAIs), also known as nosocomial infections, are a significant, yet often preventable, patient safety issue. The World Health Organization defines HAIs as “infections occurring in a patient that are acquired during the process of delivery of health care in a hospital or other healthcare facility, which were not present or incubating at the time of admission”.  Multiple factors such as advanced age, underlying immunosuppression, complex treatment modalities, duration of procedures, length of stay, and the increasing prevalence of antibiotic-resistant organisms increase the risk of HAIs. HIROC legal claims experience demonstrates that breach of infection prevention and control (IPAC) practices occurring at the time of infection are likely to cause or contribute to its transmission. Also, of growing concern is the rise of class-actions advancing claims on behalf of an array of potentially exposed patients. In addition to formal IPAC programs, a key factor in managing this risk is the coordinated contribution of environmental services, medical device reprocessing, decontamination, sterilization, surveillance practices, as well as, staff compliance at the bedside with routine infection control practices (e.g., hand washing).

Common Claim Themes

  • System

  • Inadequate management of an outbreak.
  • Facility design issues, such as:
    • Clean and dirty endoscope bins stored in close proximity to each other;
    • Insufficient or poorly placed hand washing sinks and hand sanitizer dispensers.
  • Inadequate housekeeping staffing levels and cleaning measures (e.g., wrong type and/or improper application of surface and equipment cleaning products).

Knowledge and Judgement

  • Lack of monitoring of IPAC measures and interventions.
  • Insufficient compliance with IPAC policies and guidelines.
  • Failure to isolate infected or colonized patients with the same significant antibiotic resistant organism.
  • Delayed performance of ordered screening or testing.
  • Lack of timely communication and documentation of patient symptomology (signs and symptoms of sepsis or septic shock).
  • Improper use and wear of personal protective equipment (PPE).

Documentation and Communication

  • Conflicting definitions for “outbreak” within the IPAC team and externally.
  • Delayed action and communication regarding:
    • Positive screening results to ordering practitioners, healthcare team and/or IPAC staff;
    • The presence and/or severity of an outbreak to internal and external stakeholders.
  • Poorly conducted look-backs and patient notifications (disclosure) following a large scale exposure.

Case Study 1

A patient underwent a total knee replacement and two days post-operatively experienced diarrhea which continued for three days. The patient’s fluid levels were not monitored and the patient experienced dehydration (which went undetected), elevated creatinine levels and eventual renal failure. A week after being admitted, stool cultures and a computerized tomography (CT) scan revealed Clostridium difficile (C. diff.). The patient died within 33 days of the initial diagnosis. Legal action was commenced by the family and the claim was settled as expert reviewers believed that proper infection control and isolation procedures were not utilized and that management of the infection did not meet the standard of care.

Case Study 2

An outpatient hemodialysis patient with undiagnosed active tuberculosis (TB) came in contact with hundreds of patients and healthcare providers over a five month period. Following diagnosis, the healthcare organization engaged in a large-scale look-back and patient notification process. While there was a low risk of transmission, the dialysis patients were considered at higher risk due to their immunocompromised status. The healthcare organization elected to notify all of the hemodialysis patients, encouraging them to undergo testing. Healthcare providers were also offered testing. Four patients tested positive (latent) for TB during the first round of testing. The second round of testing identified a fifth patient and one healthcare provider. Being a low risk facility for TB, TB screening was not routinely offered to hemodialysis patients. The review indicated that there was a delay in the diagnosis of the initial patient despite symptoms of active TB and the healthcare organization did not follow infection prevention guidelines regarding the layout of the dialysis unit.

Mitigation Strategies

Reliable Care Processes

  • Implement targeted evidence-based strategies (e.g., validated care bundles, standardized order sets, antibiotic stewardship program) to prevent, identify, and manage (but not limited to): 
    • Sepsis and severe sepsis;
    • Clostridium difficile. 
  • Adopt organism-specific patient screening, surveillance, isolation, and cohorting practices.
  • Limit the use of multi-dose vials for Intravenous (IV) and Intra Muscular (IM) medication.
  • Adopt a standardized aseptic technique for the insertion of epidural catheters for all pregnant persons who receive or request epidural analgesia.
  • Implement an interdisciplinary IPAC committee that reports to the Board of Directors through the Medical Advisory Committee (MAC) and/or Senior Management. 
  • Implement formal strategies to ensure the appropriate levels of and/or access to qualified Infection Prevention and Control (IPC) practitioner(s) based on patient populations, volumes, and acuity.

Outbreak Management

  • Implement a standardized evidence-based outbreak protocol that addresses the following (but is not limited to):
    • A standardized definition of ‘case’ and ‘outbreak’;
    • Processes for reporting and communicating a suspected or actual outbreak;
    • Internal and external notification requirements;
    • IPAC measures during and post outbreak;
    • Specimen collection;
    • Outbreak control strategies;
    • Monitoring outbreak status;
    • Declaring outbreak over and evaluation;
    • Restriction requirements on patients, staff, units, and programs;
    • Roles and responsibilities.

Patient and Family-Centred Care

  • Develop (or co-develop with patient and family advisors) an education program for patients and families regarding IPAC principles and the facility’s related policies including (but not limited to):
    • Their role in prevention, early detection, and management of HAIs (e.g., speaking up);
    • Risk factors, prevention, warning signs and symptoms to be aware of, including (but not limited to) sepsis;
    • The importance of communicating risk factors, symptoms, etc. to the healthcare team and/or primary community practitioner.

Equipment and Supplies

  • Implement formal strategies to ensure sufficient:
    • Easily accessible inventory of PPE and supplies;
    • Point-of-care sharps containers;
    • Numbers of ready access hand washing sinks and hand sanitizer dispensers.

Cleaning Environment and Equipment Cleaning

  • Obtain IPAC input and collaboration with environmental services related to the selection of surfaces and finishes, and appropriate cleaning and disinfecting products.
  • Establish clear environmental cleaning standards, including documentation.
  • Ensure contracts with housekeeping providers conform to IPAC guidelines and policies.

Monitoring and Measuring

  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and adherence to IPAC processes and tools, including (but not limited to):
  • Tracking and reporting the incidence of HAIs and outbreaks, by organism;
  • Aseptic technique for intramuscular injections and epidural analgesia;
  • Adoption of formal program and practitioner-specific quality measures and indicators;
  • Sharing learnings from IPAC incidents with teams and leadership (e.g., chart audits, trigger tools, incident reports, team debriefs, critical incident, quality of care committee reviews, and medical legal claims).


  • HIROC claims files.
  • 2007 Guidelines for isolation precautions: Preventing transmission of infectious agents in healthcare settings. (2019). Centers for Disease Control and Prevention.
  • College of Nurses of Ontario. (2019). Infection prevention and control. Educational Tools.
  • Banach D, Johnston B, Al-Zubeidi D, et al. (2017). Outbreak response and incident management: SHEA guidance and resources for healthcare epidemiologists in United States acute-care hospitals. Infect Control Hosp Epidemiol. 38(12):1393-1419.
  • Dancer S. (2009). The role of environmental cleaning in the control of hospital-acquired infection. J Hosp Infect. 73(4):378-385.
  • Health Canada and the Public Health Agency of Canada. (2018). Evaluation of health-associated infection activities at the Public Agency of Canada 2012-13 to 2016-17.
  • Office of the Chief Coroner for Ontario. (2007). Review of SAH C. difficile outbreak.
  • Provincial Infectious Diseases Advisory Committee (PIDAC). (2012). Best practices for infection prevention and control programs in Ontario in all health care settings. (3rd Ed.). Toronto, ON: Public Health Ontario.
  • Provincial Infectious Diseases Advisory Committee (PIDAC). (2012) Routine practices and additional precautions in all health care settings. (3rd Ed.). Toronto, ON: Public Health Ontario
  • Provincial Infectious Diseases Advisory Committee (PIDAC). (2018). Best practices for environmental cleaning for prevention and control of infections in all healthcare settings. (3rd Ed.). Toronto, ON: Public Health Ontario.
  • Society for Healthcare Epidemiology of America (SHEA). (2017). New document guides hospitals in responding to infections disease outbreaks. Infection Control Today.
  • Weber D, Rutala W, Miller M, et al. (2010). Role of hospital surfaces in the transmission of emerging health care-associated pathogens: Norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control. 38(5 Suppl. 1):S25-S33.
  • Zingg W, Holmes A, Dettenkofer M, et al. (2015). Hospital organisation, management, and structure for prevention of health-care-associated infection: A systematic review and expert consensus. Lancet Infect Dis. 15(2):212-224.
  • Zoutman D, Ford B, Sopha K. (2014). Working relationships of infection prevention and control programs and environmental services and associations with antibiotic-resistant organisms in Canadian acute care hospitals. Am J Infect Control. 42(4):349-352.