OBJECTIVE:To report our quality improvement efforts to reduce total parenteral nutrition (TPN)-associated bloodstream infections, and the results of those efforts, during the period including the first quarter of 2004 through the third quarter of 2010. METHODS:A variant on failure modes and effect analysis and existing guidelines were used to develop and modify interventions. Effectiveness of the interventions was assessed by using a graphical depiction of interrupted time-series data on TPN-associated infections per 1000 TPN-days, aggregated across quarters within intervention periods. RESULTS:Although initial interventions yielded limited reductions in infection rates, it was not until the implementation of a multifaceted "maintenance intervention bundle" that rates strongly responded. After this key intervention revision, the TPN-associated infection rate decreased between implementation in the first quarter of 2008 from 26.1 to 4.8 per 1000 TPN-days during the 8 quarters aggregated comprising the first quarter of 2008 through the fourth quarter of 2009. The final addition of an alcohol-swab cap resulted in a reduction of rates to 0 for the first three-quarters of 2010. CONCLUSIONS:Our evidence suggests that iterative design/redesign of interventions using failure modes and effect analysis has directly reduced TPN-associated bloodstream infections. KEY WORDS central line-associated bloodstream infection, total parenteral nutrition, failure modes and effect analysis, maintenance intervention bundle ABBREVIATIONS CLABSI-central line-associated bloodstream infection TPN-total parenteral nutrition NACHRI-National Association of Children's Hospitals and Related Institutions CSH-Children's Specialized Hospital FMEA-failure modes and effect analysis MIB-maintenance intervention bundleDr Castello and Ms Maher made substantial contributions to conception and design, drafting and revising the article, and acquiring the data and were part of the team involved in final approval of the manuscript; Dr Cable made substantial contributions to the design, analysis and interpretation of the data, and drafting and revising the article; and Dr Cable was part of the team involved in final approval of the manuscript.www.pediatrics.org/cgi/doi/10.1542/peds.

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