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      Patient Safety in the Dialysis Facility

      Blood Purification

      S. Karger AG

      Patient and Quality Improvement Act, Root cause analyses, Dialyzer errors

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          Medical mistakes that harm patients have occurred in dialysis facilities, just as they 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 ‘near misses’ is encouraged in a non-punitive environment. (2) Redesign processes of care to minimize patient falls, medication errors, bleeding from vascular accesses, dialyzer reuse errors and other problems. (3) Perform root cause analyses of adverse events and ‘near misses’. (4) Involve patients in safety efforts, including maintaining an accurate, up-to-date medication list. (5) Dialysis facilities should function as high-reliability organizations, focusing on the possibility of failures, expecting to make errors, training to recognize and recover from them and making system reforms following root cause analyses.

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          Most cited references 4

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          Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units.

          Previous studies found that medication errors result from lack of sufficient information during the prescribing step. Therefore, it is proposed that having a pharmacist available when patients are evaluated during the rounding process may reduce the likelihood of preventable adverse drug events (ADEs). The objectives of this study were to evaluate the impact of having a pharmacist participate with a physician rounding team on preventable ADEs in general medicine units and to document pharmacist interventions made during the rounding process. A single-blind, standard care-controlled study design was used to compare patients receiving care from a rounding team including a pharmacist with patients receiving standard care (no pharmacist on rounding team). Patients admitted to and discharged from the same general medicine unit were included in the study. The main outcome measure of this study was preventable ADEs. Patient records were randomly selected and evaluated by a blinded process involving independent senior pharmacist specialists and a senior staff physician. Interventions made by the pharmacists in the treatment group were documented. The rate of preventable ADEs was reduced by 78%, from 26.5 per 1000 hospital days to 5.7 per 1000 hospital days. There were 150 documented interventions recommended during the rounding process, 147 of which were accepted by the team. The most common interventions were (1) dosing-related changes and (2) recommendations to add a drug to therapy. Pharmacist participation with the medical rounding team on a general medicine unit contributes to a significant reduction in preventable ADEs.
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            Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center.

            In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions occurred in outpatients at a hemodialysis center.
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              Patient safety in end-stage renal disease: How do we create a safe environment?

              The Institute of Medicine estimated that 44,000 to 98,000 hospitalized patients die annually as a direct result of preventable medical errors. Errors occur because competent practitioners are human, and the systems we design are imperfect. Improving patient safety requires acknowledging medical errors, encouraging the reporting of errors, and improving systems to reduce the likelihood of future errors. Several challenges must be addressed to accomplish this goal. The definition of medical errors must be widely agreed on and accepted. Adverse outcomes are often the result of multiple systems failures. Therefore systems analysis, not blaming an individual, should be the focus of error reduction. A "culture of safety" should be created, which encourages reporting errors and "near-misses." An effective reporting system has 2 components, one for public accountability for errors that result in serious injury and another for confidential reporting of mistakes that have the potential for serious injury. Regulatory protection from discovery must be established for voluntary error and near-miss reporting systems. In the nephrology community, novel uses of technology should be sought to prevent errors, human factors leading to errors should be identified and anticipated, and patterns of interaction at the machine-human interface should be studied. Progress in improving patient safety has occurred in some areas, such as pharmacy services. Such known and tested patient safety practices should be deployed in dialysis facilities. Success in improving patient safety will require leadership, collaborative efforts among the many stakeholders in the ESRD program, and adequate allocation of resources. Copyright 2001 by the National Kidney Foundation, Inc.

                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                December 2005
                23 December 2005
                : 24
                : 1
                : 19-21
                Yale University School of Medicine, and Department of Medicine, Hospital of St. Raphael, New Haven, Conn., USA
                89431 Blood Purif 2006;24:19–21
                © 2006 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

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