It has been well established that good hand hygiene is essential for the prevention of infection. Nurses wash their hands with the provided alcohol hand gel as they enter and exit patients’ rooms. Recently a nurse has begun to notice the hand sanitizer systems are empty in many patients’ rooms. Staff often become distracted before finding hand sanitizer and, because the sanitizer systems are empty, are failing to clean their hands after patient contact. The nurse begins to wonder about how the holders get filled, how often, and by whom.

1.

What CUES (Assessment) should the nurse consider?

2.

What HYPOTHESIS (Diagnosis) should the nurse consider?

3.

What ACTION (Plan and Implement) will be most effective for the nurse to take to improve adherence to hand washing?

4.

What OUTCOME (Evaluation) metric will determine successful QI?