title: Improving water quality in a dialysis unit using root cause analysis.
abstract: BACKGROUND
  Water quality levels from hemodialysis (HD) and reverse osmosis (RO) machines in dialysis units must meet standards set by the American Association of Medical Instrumentation. Researchers used a root cause analysis (RCA) approach to identify and address factors affecting water quality in the HD and portable RO machines at our institution.
  
  
  METHODS
  A multidisciplinary team reviewed processes, interviewed staff members, and identified opportunities to improve the current sampling and machine disinfection processes. The RCA team identified and implemented 5 interventions, of which 3 were process (changes in water sampling technique, machine disinfection processes, and allocation of machine maintenance duties) and 2 were structural (regular cleaning of water sampling tubes and spigots and addition of new water sampling sites in the system) measures.
  
  
  RESULTS
  Postimplementation of new protocols, 100% of water cultures of HD and RO machines consistently met the required regulatory standards as recorded over a period of 8 months.
  
  
  CONCLUSIONS
  RCA approach helped improve patient safety, quality of care, streamlined processes, and improved efficiencies of work for staff within the HD program.
authors.affiliation: Department of Infection Prevention, University of Minnesota Medical Center, Minneapolis, MN.
authors.forename: Pallavi
authors.initials: P
authors.lastname: Yadav
authors.affiliation: Department of Infection Prevention, University of Minnesota Medical Center, Minneapolis, MN.
authors.forename: Dawn
authors.initials: D
authors.lastname: England
authors.affiliation: Adult and Pediatric Dialysis Unit, University of Minnesota Medical Center, Minneapolis, MN.
authors.forename: Caprice
authors.initials: C
authors.lastname: Vanderkolk
authors.affiliation: Department of Infection Prevention, University of Minnesota Medical Center, Minneapolis, MN; Division of Pediatric Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN. Electronic address: irohtam@mlw.mw.
authors.forename: Pui-Ying
authors.initials: PY
authors.lastname: Iroh Tam
mesh_terms: D004203:Disinfection / Q000379:methods*; D006436:Hemodialysis Units, Hospital; D006801:Humans; D007688:Kidneys, Artificial; D006435:Renal Dialysis / Q000295:instrumentation* / Q000379:methods*; D060753:Water Quality
keywords: Hemodialysis; Patient safety; Quality improvement; Reverse osmosis; Sphingomonas paucimobilis