Improving water quality in a dialysis unit using root cause analysis

Pallavi Yadav, Dawn England, Caprice Vanderkolk, Pui-Ying Iroh Tam

Research output: Contribution to journalArticle


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.

Original languageEnglish (US)
Pages (from-to)799-804
Number of pages6
JournalAmerican journal of infection control
Issue number7
StatePublished - Jul 1 2017


  • Hemodialysis
  • Patient safety
  • Quality improvement
  • Reverse osmosis
  • Sphingomonas paucimobilis

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