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INVESTIGATION INTO SAFETY MANAGEMENTOF MEDICAL HAEMODIALYSIS
Submitted to: Dr Graham Richard
Submitted by: Md. Nazmul Hoque.S.I.D: S104R0153Submitted date: 11th of December
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Acknowledgement
Medical mistakes that harm patients have occurred in dialysis facilities, just asthey have been reported to cause death in hospitals. A plan to recognize and
prevent mistakes includes several elements. (1) Establish a culture of safety,where safe practices are a priority and reporting of adverse events and 'nearmisses' is encouraged in a non-punitive environment. (2) Redesign processes ofcare to minimize patient falls, medication errors, bleeding from vascularaccesses, dialyzer reuse errors and other problems. (3) Perform root causeanalyses of adverse events and 'near misses'. (4) Involve patients in safetyefforts, including maintaining an accurate, up-to-date medication list. (5) Dialysisfacilities should function as high-reliability organizations, focusing on thepossibility of failures, expecting to make errors, training to recognize and recoverfrom them and making system reforms following root cause analyses.
In 1999, the Institute of Medicine reported that as many as 98,000 Americans dieeach year in hospitals as the result of medical errors. Since that time, all hospitalshave implemented new practices to improve patient safety. Most doctors, nursesand health care administrators have worked to establish a culture of safety,where safe practices are a priority and reporting of adverse events and nearmisses is encouraged in a non-punitive environment to find faulty systems ofcare and reduce errors. These days, we do not have to go far to find evidence ofmistakes that harm patients with kidney disease. In February 2003, a teenagerfrom Mexico died after she mistakenly received a kidney transplant from a donorwith a different blood type. In June 2004, hundreds of patients in BritishColumbia, Canada were tested for hepatitis after several dialysis machines werefound to have leaks, potentially exposing patients to the blood of others who hadbeen dialyzed on that same machine. In 2001, blood stream infections werefound in hemodialysis patients who had received contaminated erythropoietininjections.
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Contents
Chapter 1 pg 4
Chapter 2 pg 7
Chapter 3 pg 8
Chapter 4 pg 10
Chapter 5 pg 11
Chapter 6 pg 18
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Chapter 1: Background
In 1987, two hospitals of UK reported that two medical incidents in which nursing
staff inadvertently connected patient electrocardiogram (ECG) lead wires to the
main supply power. As a result, these patients received electric shocks. Oneincident resulted in death by electrocution; and the other one made severe third-
degree burns that need to undergo plastic surgery. The cause for the hazard was
investigated because of inappropriate connection of two medical device
componentsunprotected patient electrode lead wires and detachable device
line cords. (MDSR, 1987)
More severity, August 20, 1998 in Hong Kong, three dialysis patients were killed
and three patients were admitted to Intensive Care Unit (ICU ) with a critical ill
involving a medical incident, which occurred in the Renal Dialysis Unit of the
Hong Kong Sanatorium and Hospital. At the very beginning of haemodialysis on
that day, the patient started to vomit and shake one by one. Not until thehaemodialysis machine alarm responded, the nurse stopped the machine.
Unfortunately, it seems to be too late! It is said that the patients started to feel
uncomfortable however these patients were ignored by the nursing staff there.
After that, one Investigation Team of the Department of Health found the incident
was happened from contamination of the water treatment system used for
haemodialysis and a multitude of factors acted together to result in this event.
The water was thought to be cleaning fluid, but it pumped through an under-
maintenance kidney dialysis machine. In fact, the report highlighted that if more
supervision was paid to the operation of the machine as well as the one who
operates it, the accident might be avoided!The above two stories quoted as examples, patient safety is a serious global
public health issue. World Health Organization (WHO) estimates that tens of
millions of patients worldwide suffer to injure or death from medical error each
year due to unsafe medical practices and care. In developing countries, the
probability of patients being harmed in hospitals is higher than in industrialized
nations. At least 50 of medical equipment in developing countries is unusable or
only partly usable in view of the equipment is not often used due to lack of popper
training or skill. As result, diagnostic procedures or treatments cannot be
performed. This leads to substandard or hazardous diagnosis or treatment that
can pose a threat to the safety of patients and may result in serious injury ordeath. The economic benefits of improving patient safety are compelling.
In 1999 USA, the Institute of Medicine (IOM) of the National Academy of
Sciences released a report, To Err is Human: Building a Safer Health
System.The report stated that medical errors result in the deaths of about 98,000
people every year. Even using the lowest estimate, this would make medical
errors the eighth leading cause of death in the UShigher than motor vehicle
accidents, breast cancer, or AIDS. The report estimates that medical errors cost
the US approximately $37.6 billion each year. The costs associated with
preventable errors are estimated to be between US$17 and $29 billion. Thereport also discussed the scale of medical errors arising from poor device design,
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based on an extensive review of medical error data and interviews with device
developers.
In Canada, between 1987 and March 2003, Health Department received reports
of 425 separate incidents involving infusion pumps. Of the 425 incidents, 23
resulted in death, 135 resulted in injury, and 127 could potentially have led to
death or injury. In the UK the situation is similar. According to the Medical
Devices Agency of UK (MDA, 1999), over 66,000 adverse incidents involving
medical devices were reported. It included 87 deaths and 345 serious injuries.
Furthermore, in the five years to 2007, there are received 530 adverse incidents
relating to dialysis machines and their associated equipment and disposables.
Another, in the Australian Incident Monitoring Study reported that 177 incidents
were due to "pure" equipment failure according to pre-defined criteria. The report
estimated 107 (60%) involved anesthetic equipment, 42 (24%) involved monitors,
17 (10%) other theatre equipment and 11 (6%) the gas or electricity supply.
Ninety-seven (55% of the 177) were potentially life-threatening. Studies show that
additional hospitalization, litigation costs, infections acquired in hospitals, lost
income, disability and medical expenses have cost some countries between US 6
billion and US 29 billion a year. Nowadays, due to technological advances,
medical devices play an increasingly important role in the healthcare
organizations; the public gradually expresses concern over the safety use of
medical devices.
These data are truly shocking. There is a heightened awareness among all
healthcare professionals. The safe use of medical device is an important
component of many patient safety initiatives. It is reflected in the credo first do no
harm shared by all medical and allied health professionals. Nowadays,healthcare professionals should take a period of considerable change in their
attitude towards medical error and their understanding of its causes.
Haemodialysis in Hong Kong
While the treatment of End Stage Renal Disease is one of the tremendous
success stories of modern medicine, medical mistakes that harm patients have
occurred in renal dialysis unit as well; just they have been report to cause death
in Hong Kong hospital., Nowadays, Hong Kong people have been given attention
to the occurrence of medical errors and concerned with patient safety. There are
many researches and approaches to explore the safe use of medication and thequality assurance in surgical operation from other countries. However, there are
few researches to assess the safe use of high risk medical devices in dialysis
facilities although some of health care professionals, patients, and others are
aware of cases of error in this field, perhaps most notoriously during
hemodialysis.
Furthermore, despite efforts of the Medical Devices Control Office, which issues
safety warnings, adverse incidents with medical devices continue to occur, some
of which result in serious injury or death through device failures, user errors, and
organisational problems .In addition, the Hospital Authority of Hong Kong is
perceived to have a poor record of medical incidents. For instances, there arefew data on staffs competence audit in using high risk equipment; no consistent
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guideline on the safe use and maintenance of medical equipment; no popper
hospital-wide monitoring system on the safe use of medical equipment, and no
details of data on patient incidents due to unsafe use of medical equipment.
Because so many problems occurred, ranging in severity from insignificant to
catastrophic, it is important to select the patient safety problems for analysis,
especially, equipment safety is a crucial factor of good patient care in the
hemodialysis process.
Owing to the hemodialysis population in Hong Kong keeps increasing these
years, we should paid more attention to patient safety with the growing
hemodialysis population.
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Chapter 2: Aim
This study may be used to help mention these problems in a structured way, with
the intent of preventing their recurrence. To address the challenge of improving
dialysis patient safety regarding to use of high risk medical devices; this paperinitiates a study to address these issues.
The Aim of Study as below: Analyses of the high risk medical device incidents to explore the back-
ground conditions as well as the triggering factors and unsafe actions. To help prevent repetitions and contribute to an open supportive
environment. Developing Continuous Quality Improvement on safe use of medical
devices hazard in Renal Dialysis Centers.
Structure of Thesis
This paper presents the results of an investigation into medical errors in the UKand the USA, and focuses in particular on the magnitude and causes of errors
when using medical devices. Contrary to the traditional approach of blaming
users, it is suggested here that many such errors are caused partly by poor
device design, which fails to account adequately for the needs of users. In
response, this paper also discusses the basics of a Human Factors Engineering
(HFE) approach as a step towards overcoming this problem and offers a
challenge to device users and design companies (manufacturers) to follow HFE
principles in order to improve the efficiency of operation and reduce errors during
device use.
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Chapter 3: Literature Review
The purpose of this review is to provide a framework for viewing success and its
measurement in quality and safety management of device related to medical
error, and, specifically, to examine the causes influence successful management
outcomes.
The literature review that follows is organized the main sections intended to
address the following research questions:
What are the definition of patient safety and medical error in healthcare?
What is the relation between haemodialysis and patient safety at arenal dialysis centre?
What are the current system to assess the safety, effectiveness and
quality of medical devices to safeguard patient health? How is success defined in safety management? Specifically, how do
patient define success? What factors are involved in safety management in a dialysis center
success? How do the different quality improvement approaches to reduce errors? How should we manage the high risk medical devices in a dialysis
center?
The literature review will consist of four primary sections. The first section will
focus on the challenge of patient safety. The second section will review the
interrelationships between haemodialysis and patient safety. The third section willexamine and discuss the current practice and solutions on critical issues in
managing change. The fourth section will discuss various quality improvement
approaches to reduce errors.
Document
Records
Patient Safety
Maintainer
Control System
Device Design
Management ofHigh Risk Medical Devices
Dialysis Center
Management
Approaches
Medical Devices Classification
Staff Training
User
Government
Regulation
Medical Incident
Customer Education
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Medical device, many people tend to describe that complex, highly technical
equipment used in acute healthcare facilities. However, medical devices cover a
broad range of products, including highly complex and sophisticated products
such as Magnetic Resonance Imaging System to simple products such as
bandages and thermometers.
By the classification rules of the MDACS, medical devices are classified into four
categories (Class I to IV) According to their risk levels, Class IV being the
category of the highest risk and Class I the lowest.
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Chapter 4: Methodology
Research is an important tool for improving patient safety which contributes to a
better understanding of the extent and causes of unsafe care, as well as
developing and evaluating the impact of solutions on reducing patient harm. The
Research Programme was set up by the WHO World Alliance for Patient Safety
to foster research for patient safety worldwide and help foster the development of
national patient safety research agendas. WHO has formulated an expert working
group in this concern?
Research Question Select Search Terms Select Inclusion & Exclusion Criteria Analysis Research Findings Conclusion
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CHAPTER 5: Analysis
A survey of large dialysis organizations conducted by the Renal Physicians
Association, the Forum of End- Stage Renal Disease Networks and the National
Patient Safety Foundation identified several safety problems in dialysis facilities:
patient falls, medication errors, vascular access-related events, dialyzer errors,
excess blood loss and prolonged bleeding.
Several highly publicized cases of medical mistakes in dialysis and transplant
patients underscore the need for the end-stage renal disease community to deal
with this troubling problem. In one hemodialysis center, 10 Serratia
liquefaciens bloodstream infections and 6 pyrogenic reactions resulted from
puncturing single-use vials of epoetin-multiple times and pooling the
preservativen free drug [5] In June 2004, hundreds of patients in British
Columbia, Canada, were tested for hepatitis after several dialysis machines were
found to have leaks, potentially exposing patients to the blood of others who had
been dialyzed on that same machine. Finally, in February 2003, a teenager from
Mexico died at Duke University after she mistakenly received a kidney transplant
from a donor with a different blood type. Many institutions and dialysis facilities
have made progress in process redesign to improve patient safety.
Another source of error is giving medicine or reprocessed dialyzers to the wrong
patient. In March 2004, the Federal Drug Administration issued a rule requiring
that certain human drug and biological product labels have bar codes. This bar
coding is expected to help reduce the number of medication errors by allowing
health care professionals to use bar code scanning equipment. Dialysis facilities
can use bar-coded patient identification bracelets or identity cards to confirm
correct administration of medications, reused dialyzers and other procedures.
Dialysis patient safety is a complex issue that involves highly specialized dialysis
technology, staff training and turnover, cost pressures, reporting of problems,
oversight and regulations, water purification, dialyzer reuse, medication errors,
patient compliance, patient education, primary care, prevention, vascular access,
infection, location and layout of dialysis units, and the increased age and
comorbidities of the ESRD population.
Institute of Medicine (IOM, 2000) defined patient safety as the freedom from
accidental injury due to medical care or from medical error. It indicated that
Patient safety is emphasized the reporting, analysis and prevention of medicalerror and adverse healthcare events . Since the Institute of Medicine (IOM)
reports published, national attention has focusedon improving patient safety
through changes in "systems" ofcare.
Beginning in 1997, the Joint Commission added new patient safety improvement
standards. In further, The National Patient Safety Agency (2003) described
patient safety as the process by which an organisation makes patient care safer.
This should involve: risk assessment; the identification and management of
patient related risk; the reporting and analysis of incidents; and the capacity to
learn from and follow up incidents and implement solutions to minimise the risk of
them recurring.
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In July 2004, Healthgrades, a leading health care ratings organization, published
a study, Patient Safety in American Hospitals ( ). It concluded that there were
over one million adverse events associated with Medicare hospitalizations during
2000-2002, resulting in up to 195,000 accidental deaths per year in American
hospitals. Then, numerous organizations, government branches, and private
companies conduct many research studies to investigate the overall health of
patient safety in America and across the globe. Despite the shocking and widely
publicized statistics on preventable deaths due to medical errors in Americas
hospitals, the report of National Healthcare Quality(2006) had the following
sobering assessment: most measures of Quality are improving, but the pace of
change remains modest. The rate of improvement accelerated for some
measures while a few continued to show deterioration. Variation in heath care
quality remains high.
In October 2004, World Health Organization (WHO) launched the World Alliance
for Patient Safety in response to a World Health Assembly Resolution (2002) - to
pay the closest possible attention to the problem of patient safety. Then, all WHO
Member States develop patient safety initiatives and policy. The patient safety
initiatives include application of lessons learned from business and industry,
advancing technologies, education of providers and the public, disclosure of
errors, and economic incentives.
Dialysis patient safety is a complex issue that involves highly specialized dialysis
technology, staff training and turnover, cost pressures, reporting of problems,
oversight and regulations, water purification, dialyzer reuse, medication errors,
patient compliance, patient education, primary care, prevention, vascular access,
infection, location and layout of dialysis units, and the increased age and co-morbidities of the ESRD population.
Patient Safety in the Dialysis Facility
There are many possible causes for patient injury within the dialysis environment.
The process of providing dialysis treatments includes the use of medications,
chemicals, machinery, and physical activity on the part of the patient. When time
constraints and staffing difficulties are added to the equation, it is understandable
how and why injuries occur. Some common sources of injuries are listed below:
Medication errors
Blood administration errors
Falls Equipment malfunction
Chemical exposure
Medical Record errors
Similar Name errors
Deviation from policy & procedure
Infection control errors
Dialysis prescription errors
By examining each of these sources individually, common root causes of errors
can be explored and practical solutions developed to prevent future errors and/or
patient injury.
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Medication Errors
According to the 1998-2001 National Coordinating Council for Medication Error
Reporting and Prevention (NCC MERP), A medication error is any preventable
event that may cause or lead to inappropriate medication use or patient harm
while the medication is in the control of the health care professional, patient, or
consumer. Such events may be related to professional practice, health care
product, procedure, and With the advances in the practice of medicine come new
drugs to treat disease. Each drug administered in the dialysis facility brings with
it the potential for human errors. First, it is important to review the five rights
basics of drug administration that nurses are taught early in drug administration
training: right patient; right time; right drug; right dosage; and right route. Errors
can happen when one or more of the rights are missed. Just knowing and
using the five rights cant prevent all errors, but it is a place to begin! To further
complicate matters, many medications are packaged similarly. Any drug dosage
can be miscalculated or given to the wrong patient. Also added to the picture is
the fact that non-licensed staff members are administering routine medications
(such as Heparin and Lidocaine) in the dialysis setting. Sometimes agency-based
dialysis nurses are utilized to maintain staffing ratios. These temporary staff
nurses may not be able to identify patients or be familiar with the facility
protocols. Unlike the hospital setting, dialysis patients in the outpatient facility do
not wear name band identification bracelets.
It is sobering to think about errors that have happened in good dialysis units.
Patients have received Hepatitis B vaccine intravenously instead of
intramuscularly. Overdoses of Heparin can be easily administered. Seriousreactions have occurred from iron administration. Antibiotic administration must
be carefully performed as patients may have multiple medication allergies.
Careful attention needs to be paid to the packaging and storage of medications.
Heparin has been mistaken for Lidocaine and vice-versa- each is a clear solution
and may be packaged in similar vials. When possible, avoid purchasing products
with similar packaging. However, some corporate purchasing contracts limit the
number of available vendors. If look-a-like packaging is unavoidable, try to
store products in different locations or draw further attention to the product by
using brightly colored alert stickers or another means of alert.
The labeling of medication syringes is imperative. The name of the drug, dosage,
time, date, and patient name should be clearly indicated. Commercial labels are
available to aid staff members in quickly preparing syringes. Ideally, syringes are
prepared at the time of use, and administered by the individual that prepared it.
Blood Administration Errors
When administering blood products in a dialysis setting, special considerations
must be taken. First, the physicians order must be accurately communicated to
the blood bank and patient consent obtained. Follow the facility policies andprocedures for proper identification of the patient, administration of blood
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products, and monitoring the patient before, during, and after the receipt of the
blood.
During dialysis, blood can be given more rapidly than in other settings. It is very
easy to miss monitoring the patients vital signs during rapid administration. Care
must be taken to monitor the patient adequately during administration. The
patient must be aware of the signs and symptoms of a blood reaction following
administration. Careful documentation of the entire process is important.
Patient Falls
The average age of dialysis patients is now roughly 65 years of age. Patients
frequently have co-morbid conditions that can affect their ability to ambulate.
Utilizing patient assist devices such as walkers, canes, or wheel chairs can be of
help. Staff member training in the proper techniques of patient transfer is
important to prevent injury to either the patient or staff member.
The dialysis environment requires the use of water and many other liquid
products. Falls can occur when liquids or powders are spilled on the floor
identifying wet floors, and having equipment readily available to mop up spills can
prevent injury, especially during the change of shift when more people are
present in the treatment area.
Take the time to evaluate the environment of the dialysis center for hazards that
can cause falls and follow up with preventative measures.
Equipment Malfunction
When equipment or maintenance problems cause patient deaths or seriousinjuries, these should be reported to the manufacturer and/or the Federal Drug
Administration (FDA) as appropriate and steps taken to prevent similar
occurrences from happening in the future.
In dialysis settings, it is important to remember to be able to track the lot numbers
of items such as, but not limited to, machine tubing, drugs, and dialyzers. In the
event of manufacturing defects, the lot numbers can be used to identify facilities
at risk or batches of product that are affected.
The Medicare Condition for Coverage 410.2140, states:
The physical environment in which ESRD services are furnished affords a
functional, sanitary, safe, and comfortable setting for patients, staff and thepublic.
All electrical and other equipment used in the facility is maintained free of defects,
which could be a potential hazard to patients and personnel. There is established
a planned program of preventive maintenance of equipment used in dialysis and
related procedures in the facility.
Chemical Exposure
Any chemical must be treated with respect, as the potential for patient exposure.
A variety of chemicals such as dialysate, vinegar, bleach, Renalin, and
formaldehyde are used in the dialysis facility. Bleach is used to wipe downsurfaces in a facility to prevent the spread of blood borne pathogens posing a risk
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for patient exposure. It is possible to fling bleach onto patients sitting nearby.The
packaging of some chemical is similar in nature. Many chemicals are contained
in jugs or plastic bottles that can be mistaken for one another. Obtaining and
maintaining material safety data sheets (MSDS) on all chemicals is an
Occupational Safety and Health Administration (OSHA) requirement. Never use
anything from an unlabeled container!
Medical Record Errors
In the dialysis facility, the physical location of the patient chart, Kardex, and
treatment flow sheet clipboard may not always be near the patient. In some
facilities, only the clipboard with the treatment flow sheet is at the chair side with
the patient. Vital information about the patients allergies, co-morbid conditions,
medications, dialysis prescription, must be readily available to care givers.
Failure to indicate allergies can be catastrophic. Audit your facility treatment flow
sheets to determine if vital information is included. Computerized treatment flow
sheets are a wonderful by product of advances in dialysis technology. However, it
is possible to become overly reliant on the computer-generated documentation.
At the Network, we recently reviewed thousands of flow sheets and discovered
that even the computerized sheets lack necessary information. The old computer
adage of garbage in/ garbage out applies. The machine operator must input the
appropriate data for the machine to output a complete record of the treatment.
Avoid the pitfall of relying on a false sense of security when using computerized
sheets.
Handwritten treatment flow sheets are often very difficult to read. Not only do
staff members have varying degrees of handwriting skills and the use ofunidentifiable abbreviations only increases the possibility of errors. Physicians
have traditionally been ridiculed for illegible handwriting. After the Network
review of handwritten flow sheets, it is safe to say that all staff members have the
potential for messy writing.
Deviation from Facility Policy & Procedure
When a staff member operates outside of the protection of facility policies and
procedures, the patient, staff member, facility, and possibly corporation are put at
great liability risks. The importance of following policies and procedures cannot
be over emphasized. As stated in the Medicare Conditions for Coverage405.2136:
The ESRD facility has written policies, approved by the governing body,
concerning the provision of dialysis and other ESRD services to patients. The
governing body reviews implementation of policies periodically to ensure that the
intent of the policies is carried out. These policies are developed by the hysician
responsible for supervising and directing the provision of ESRD services, or the
facilitys organized medical staff (if there is one), with the advice of (and with
provision for review of such policies from time to time, but at least annually, by) a
group of professional personnel associated with the facility, including, but not
limited to, one or more physicians and one or more registered nurses
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experienced in rendering ESRD care. The physician-director of the facility is
designated in writing to be responsible for the execution of patient care
policies. If the responsibility for day-to-day execution of patient care policies has
been delegated by a physician director to (or, in the case of a self-dialysis unit, to
another licensed health practitioner) a registered nurse, the physician-director
provides medical guidance in such matters.
Infection Control Errors
Even with the availability of Hepatitis B vaccine, it is still important to protect the
dialysis patient from blood borne pathogens and other sources of infection in the
dialysis facility. Following the facility policy for disinfecting surfaces,
administration of vaccine, and laboratory surveillance remains a high priority.
Acquired immune deficiency (AIDS), Tuberculosis, Hepatitis B, Vancomycin
Resistant Enterococcus (VRE), and Methicillin Resistant Staphylococcus auras
(MRSA) are just a few examples of pathogens potentially present in a dialysis
facility. Additionally, getting back to the basics of good hand washing techniques
cannot be stressed enough.
Dialysis Prescription Errors
The dialysis prescription is an individualized method for administering the most
beneficial dialysis treatment to the patient. Components of the dialysis
prescription include treatment duration, model and size of dialyzer, blood flow
rate, and dialysis flow rate. Deviation from the prescription can result in injury to
the patient or inadequate treatments. During a recent flow sheet audit, the
Network staff reviewed over 2,000 flow sheets comparing them to the dialysisprescription. Of the 2685 flow sheets reviewed, 93.9% of the patients achieved
the correct duration of treatment, 95.9% documented that the patients received
the correct dialyzer, and 91.4% of the patients achieved the correct blood flow
rate. While these numbers are good there is more room for improvement.
Inadequate documentation was noted on both computerized and handwritten
sheets. Provide your Medicare beneficiaries with the dialysis prescription written
by the physician for which you are being reimbursed by CMS.
Adequate Staffing in the Dialysis Facility
It is not the intention of this article to define adequate staffing ratios, but facilitiesproviding dialysis service to Medicare beneficiaries must staff according to the
needs of the patients. By evaluating your own unique dialysis patient population,
staff training, and patient needs, your patient care team can determine the
properly trained personnel are present in adequate numbers to meet the needs of
the patients, including those arising from medical and non-medical emergencies.
(a) Standard: Registered Nurse, The dialysis facility employs at least one full time
qualified nurse responsible for nursing services. (b) Standard; On-duty personnel,
whenever patients are undergoing dialysis: (1) One currently licensed health
professional (e.g., physician, registered nurse, or licensed practical nurse)
experienced in rendering ESRD care is on duty to oversee ESRD patient care;(2) An adequate number of personnel are present so that the patient/staff ratio is
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appropriate to the level of dialysis care being given and meets the needs of
patients; and (3) An adequate number of personnel are readily available to meet
medical and non-medical needs.
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Chapter 6: ConclusionIt is the responsibility of all health care providers to work together to promote a
safe environment for patients in the dialysis care setting. Any error that causes
harm to a patient is on error too many. Said Dr. Nancy Dickey, past president of
the American Medical Association Would you be comfortable allowing yourfavorite family member or a good friend to receive his or her dialysis treatments
at your facility? If not, work creatively with your care team to improve systems at
your dialysis center. Errors can be prevented by designing systems that make it
hard for people to do the wrong thing and easy for people to do the right thing.
said William Richardson, President of the W. K. Kellogg Foundation. What
proactive steps can your facility take to make dialysis treatments safer for your
patients?
A national program, 5 Steps to Safer Health Care, urges patients to:
Speak up if you have questions or concerns. Keep a list of all your medications. Make sure you get the results of any test or procedures. Talk with your doctor and health care team about your options. Make sure you understand what will happen if you need surgery.
We should ask our doctor and healthcare team about safety efforts in yourdialysis unit. Is there a culture of safety where patients and staff are encouragedto report mistakes, adverse events and near-misses in a non-punitiveatmosphere, where fingers of blame will not be pointed but action will be taken toimprove systems of care? Is there a program to reduce falls and to regularly
review medications and avoid bad drug interactions? If dialyzers are reused, whatsystems are in place to prevent wrong patient assignments to dialyzers? Haveprocesses of care been reviewed to simplify and standardize? Are checklistsused? Are you doing your part to ensure your safety?
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References Kliger AS, Diamond LH. Patient Safety in End-Stage Renal Disease: How Do
We Create a Safe Environment? Advances in Renal Replacement Therapy,
Vol 8, No 2 (April), 2001: pp 131-137.
Diamond LH. Patient safety: the challenges and opportunities for the ESRD
program. Adv Ren Replace Ther 2000 Oct; 7(4 suppl 1):S100-4.
Kohn LT, Corrigan J, Donaldson MS et al: Committee on Quality of Health
Care in America. To err is human: Building a safer health system.
Washington, DC, National Academy Press 1999.
Medicare Conditions for Coverage
2001 Hemodialysis Adequacy Quality Improvement Project, ESRD Network
#12, flow sheet audit preliminary data.
Four Simple Steps to Reduce Errors. Drug Topics, Medical Economics Co.
April 6, 1997.
Medical Errors Preventable. Neergaard L. Associated Press 2000.
Pepper GA. Errors in drug administration by nurses. From Understanding
and Preventing Drug Misadventures Conference.
Singer D, Collaborative Leadership For and ESRD Patient Safety Initiative is
Formed. Contemporary
Dialysis & Nephrology April 2001: pp 36-38.
This was supported under CMS contract HHSM-500-20
CHAPTER 5. RESULTS
CHAPTER 6. ANALYSIS
CHAPTER 7. DISCUSSION
CHAPTER 8. RECOMMENDATIONSCHAPTER 9. CONCLUSION
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Recommended