Unbundling the Bundles: Using Apparent and Systemic Cause Analysis to Prevent Health Care-Associated Infection in Pediatric Intensive Care Units.

Today's health care environment emphasizes patient outcomes, although financial incentives and penalties have placed a high priority on elimination of health care-associated infections (HAIs). The use of standardized care bundles is evidence-based; however, implementation of these bundles has not proven effective in eliminating HAIs. Actively learning from HAI events through the use of apparent and systemic cause analysis identifies new barriers to success and opportunities for improvement in further reducing HAIs. The effective use of apparent and systemic cause analysis requires a standardized review and is followed with the implementation of appropriate steps to remove newly identified barriers.