Improving water quality in a dialysis unit using root cause analysis

•Sphingomonas paucimobilis was identified in dialysis water cultures.•Root cause analysis (RCA) approach was utilized to identify and address factors.•RCA team identified and implemented 3 process and 2 structural measure interventions.•After implementation of measures, 100% of water cultures met regulatory standards.•RCA is an effective tool to implement sustainable improvements in dialysis.

BackgroundWater 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.MethodsA 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.ResultsPostimplementation 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.ConclusionsRCA approach helped improve patient safety, quality of care, streamlined processes, and improved efficiencies of work for staff within the HD program.