title: Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections.
abstract: OBJECTIVE
  Central line-associated bloodstream infections (CLABSIs) in NICU result in increased mortality, morbidity, and length of stay. Our NICU experienced an increase in the number of CLABSIs over a 2-year period. We sought to reduce risks for CLABSIs using health care failure mode and effect analysis (HFMEA) by analyzing central line insertion, maintenance, and removal practices.
  
  
  METHODS
  A multidisciplinary team was assembled that included clinicians from nursing, neonatology, surgery, infection prevention, pharmacy, and quality management. Between March and October 2011, the team completed the HFMEA process and implemented action plans that included reeducation, practice changes, auditing, and outcome measures.
  
  
  RESULTS
  The HFMEA identified 5 common failure modes that contribute to the development of CLABSIs. These included contamination, suboptimal environment of care, improper documentation and evaluation of central venous catheter dressing integrity, issues with equipment and suppliers, and lack of knowledge. Since implementing the appropriate action plans, the NICU has experienced a significant decrease in CLABSIs from 2.6 to 0.8 CLABSIs per 1000 line days.
  
  
  CONCLUSIONS
  The process of HFMEA helped reduce the CLABSI rate and reinforce the culture of continuous quality improvement and safety in the NICU.
authors.affiliation: Children's Hospital, Boston, MA 02115, USA.
authors.forename: Celeste J
authors.initials: CJ
authors.lastname: Chandonnet
authors.forename: Prerna S
authors.initials: PS
authors.lastname: Kahlon
authors.forename: Pratik
authors.initials: P
authors.lastname: Rachh
authors.forename: Michele
authors.initials: M
authors.lastname: Degrazia
authors.forename: Eileen C
authors.initials: EC
authors.lastname: Dewitt
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Flaherty
authors.forename: Nadine
authors.initials: N
authors.lastname: Spigel
authors.forename: Stephanie
authors.initials: S
authors.lastname: Packard
authors.forename: Denise
authors.initials: D
authors.lastname: Casey
authors.forename: Christine
authors.initials: C
authors.lastname: Rachwal
authors.forename: Pankaj B
authors.initials: PB
authors.lastname: Agrawal
mesh_terms: D055499:Catheter-Related Infections / Q000453:epidemiology* / Q000517:prevention & control; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D003695:Delivery of Health Care; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data*; D017211:Treatment Failure
keywords: NICU; central line–associated blood stream infections; health care failure mode and effect analysis