Maintaining Safety in the Dialysis Facility

Abstract

Errors in dialysis care can cause harm and death. While dialysis machines are rarely a major cause of morbidity, human factors at the machine interface and suboptimal communication among caregivers are common sources of error. Major causes of potentially reversible adverse outcomes include medication errors, infections, hyperkalemia, access-related errors, and patient falls. Root cause analysis of adverse events and "near misses" can illuminate care processes and show system changes to improve safety. Human factors engineering and simulation exercises have strong potential to define common clinical team purpose, and improve processes of care. Patient observations and their participation in error reduction increase the effectiveness of patient safety efforts.

Enfermagem E Metas Internacionais De Segurança: Avaliação Em Hemodiálise

“…Embora as máquinas de diálise raramente sejam causa importante de morbidade, os fatores humanos na interface da máquina e a comunicação não efetiva entre os profissionais são fontes comuns de erro. As principais causas de resultados adversos potencialmente reversíveis incluem erros de medicação, infecções, hipercalemia, erros relacionados com o acesso e quedas de pacientes (21) .…”

“…As observações dos pacientes e sua participação na redução de erros aumentam a eficácia dos esforços de segurança do paciente (21) . Verifica-se a necessidade de aumentar a vigilância dos profissionais no atendimento às metas de segurança, com especial atenção aos procedimentos invasivos e cirurgias nessa clientela por meio do time out, pausa momentânea, tomada pela equipe, antes da incisão da pele, a fim de confirmar itens essenciais à segurança do cliente (22) .…”

Systems Thinking and Leadership

“…Ending preventable infections requires leadership's commitment to achieving zero patient harm and a fully functional culture of safety throughout the organization (13,16). Culture of safety is a critical factor in dialysis infections that is frequently acknowledged but less frequently realized (18). Culture describes the unspoken norms and rules that govern the behavior of a group of individuals (19).…”

Dialysis Facility Safety: Processes and Opportunities

“…Latent errors often involve miscommunications, failure of clarity, and lapses in compliance with policies and procedures. Adverse outcomes refer to potentially preventable safety events as delineated by event reporting and by facility and patient surveys . This review will focus on specific high‐risk/high frequency events by using the processes of a high reliability organization and the tools of human factor engineering.…”

“…Safety risks associated with dialysis equipment failure, water purification, and infection control have prompted the establishment of dialysis safety guidelines and state and federal regulations . Descriptive data have identified several key areas of safety risk, including: (i) patient falls; (ii) medication errors of all types; (iii) access‐related complications; (iv) dialyzer errors including machine or dialysate‐related infections, and (v) blood loss or prolonged bleeding .…”