Health Care Failure Mode and Effect Analysis to Reduce NICU Line–Associated Bloodstream Infections
| Autor: | Stephanie Packard, Pratik Rachh, Nadine Spigel, Michele DeGrazia, Christine Rachwal, Eileen C Dewitt, Celeste J Chandonnet, Prerna S. Kahlon, Pankaj B. Agrawal, Kathleen A. Flaherty, Denise Casey |
|---|---|
| Rok vydání: | 2013 |
| Předmět: |
Catheterization
Central Venous medicine.medical_specialty Quality management business.industry medicine.medical_treatment Infant Newborn Pharmacy Audit Multidisciplinary team Catheter-Related Infections Intensive Care Units Neonatal Pediatrics Perinatology and Child Health Health care Humans Medicine Infection control Lack of knowledge Treatment Failure business Intensive care medicine Delivery of Health Care Central venous catheter |
| Zdroj: | Pediatrics. 131:e1961-e1969 |
| ISSN: | 1098-4275 0031-4005 |
| Popis: | 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. |
| Databáze: | OpenAIRE |
| Externí odkaz: |
|