During the month of July 2013 and August 2013 there was a significant increase in the infection rate for implanted devices in the cardiac electrophysiology lab. After the fourth infection in a little over a month they recognized that there was a trend and to protect the safety of their patients a change needed to occur. Ron Snyder, the nurse educator on the team, lead a quality improvement project that studied a number of different processes that are involved in implanting these devices. The infection prevention action plan was put into place on November 1st 2013. The plan included implementing interventions identified by operating rooms, changing the culture, and making infection prevention a part of every procedure. There have been no infections since November, 2013.