abc
PERFORMANCE REPORT - EXCEPTION REPORT - April 2010
Target /Core Standard: Clostridium Difficile incidence
Definition:. To achieve hospital acquired Clostridium difficile monthly ceiling target
of <5 against national target of <63 for the year (5.25 per month)
The Issue
•
10 post 48 hour Clostridium difficile toxin positive patients were reported for
the month of April which exceeds the monthly trajectory of 5.
Actions Taken
•
•
Root cause analysis (RCA) undertaken for 9:10 cases. One outstanding at
present
Action plans developed to deal with root causes identified
Next Steps
•
•
•
•
•
Infection Control Nurse who attended RCA will follow up action plans to
ensure
findings are implemented
Action plans will be followed up at Divisional Infection Prevention & Control
meetings
A summary of all findings will be presented to May Trust Infection Control
Committee meeting for review and discussion
Trial of new testing method (alongside current method) for Clostridium
difficile will be piloted for one month commencing June to reduce the
chance of false positive results
LEAD DIRECTOR – Sue Greenslade