After completing a root cause analysis for a central line-associated bloodstream infection (CLABSI) identified in the ICU, the infection prevention and control team is discussing potential corrective actions to mitigate the root causes. According to the action hierarchy, what corrective action will be most effective at producing a positive outcome?

• A. Change in process or equipment
• B. Education only
• C. Administrative reminders
• D. Policy changes in unrelated areas

Answer: (A)

The strongest move is to change the process or the equipment involved. In infection prevention, outcomes improve most when system defenses are redesigned so safer behavior is built into how care is delivered. Fixes at the process level—such as standardizing the catheter insertion and maintenance bundle, adding checklists, enforcing maximal sterile barriers, or using safer equipment—create reliable safeguards that work even if individual staff performance slips. These changes alter the way work gets done, reducing opportunities for error and directly addressing how CLABSI can occur.

Education only relies on people remembering and choosing to act correctly, which can be inconsistent. Administrative reminders aim to prompt behavior but don’t fundamentally change workflows or equipment-related risk. Policies in unrelated areas don’t target the infection pathway, so they’re unlikely to produce the desired reduction in CLABSI.