Record No ______

Version 2-September 2013

Organism data
Date of Specimen: ___/___/___ / Specimen Lab Number:______
Organism Name #1:______/ Organism Name #2: ______
Was this organism also isolated from another site?Specify: ______/ Yes No
Is this specimen associated with another signal?If yes, also complete other Signal Infection Investigations Sheet/s / Yes No
Does the result meet the criteria for diagnosis of bloodstream infection
Does not meet definition of BSI / No investigation required
Meets definition of BSI Criterion 1 2 3 / Investigation required
Place of acquisition
Healthcare associated Inpatient Non Inpatient
/ Investigation required
Community associated / No investigation required
Maternally acquired / No investigation required
Focus of bloodstream infection
Unknown focus (includes disseminated infections) / Investigation required
IVD associated http://www.health.qld.gov.au/chrisp/icare/about.asp / Investigation required
Device Type:______/ Is this an IVD-related Staphylococcus aureus BSI
Date inserted: ___/___/_____ / Date removed: ___/___/_____
Inserted by (staff type): ______/ Where: ______
Details documented? Yes No
Organ site focus: Specify:______/ Investigation required
Was this infection associated with a:
Device (other than IV device, including prosthesis)
Specify:______
Procedure / Procedure Date:___/___/____
Specify: ______
Neutropaenic Sepsis
Previously identified issues (refer previous Signal Event Sheets)
No similarity to previous events / No investigation required
Previous similar events identified / Investigation required
Comments
______
To commence Investigation, utilise details over page. Attach extra pages if additional room is required.
Issues found / Action/s to be taken / By whom / By when
Ward staff not aware that peripheral intravenous catheter (PIVC) should be reviewed daily and resited every 48 hours (Unless removal at 72 hours is anticipated).
PIVC left in situ for too long (>48 hours)
Hospital procedure does not include any recommendation for resiting/removal of PIVC
Review of documentation in chart and on patient care plan identified an absence of any inspection of the PIVC by nursing or medical staff.

Direct above issue(s)/action to relevant reporting body. Utilise when reviewing Infection Control Management Plan.

Outcome/s achieved / Reported to

Utilise outcomes during evaluation of Infection Control Management Plan or during accreditation.