ABSTRACT
In 2004, Dr. Richard Shannon and his colleagues in two intensive care units at Allegheny General Hospital in Pittsburgh eradicated central line-associated bloodstream (CLAB) infections1 within 90 days.2,3 They did so without costly new equipment or supplies. They did it mainly by standardizing the way that they inserted and cared for these IV lines, by removing them as soon as they could, and by adhering scrupulously to basic hygienic requirements for staff and visitors. They discovered that, by doing work the same way every time, if an infection or bad outcome occurred, they had a scientific way to walk back through the process, see what had gone wrong, and fix it. The free exchange of this information in a feedback loop meant that they continuously refined and improved their processes.
