- List common errors that occur in dialysis units.
- Describe steps that can be taken by dialysis units to prevent these common errors.
- Describe the role of the dialysis unit medical director in promoting patient safety in dialysis units.
- List the regulatory agencies with a role in dialysis unit patient safety oversight.
A 48-year-old man with a long history of diabetes and end-stage renal disease (ESRD) on hemodialysis arrived at his outpatient dialysis center for his scheduled Friday morning session. Before starting dialysis, his nephrologist sat down next to him and stated that a serious error had occurred at the dialysis center. The nephrologist told the patient that, for a number of dialysis sessions, he had been dialyzed using a dialysis membrane that had been inappropriately reused, which meant that he had been exposed to another patient's blood many times.
The dialysis center was actually not sure which dialysis membrane had been reused, so they couldn't identify the specific patients affected by this error. Thus, they were informing all patients who had potentially been exposed to a communicable disease. At this dialysis center, many patients had HIV and hepatitis C, so it was conceivable that this particular patient had been exposed.
The patient was tested for HIV and hepatitis viruses and was treated for 3 months with postexposure prophylaxis for HIV. Ultimately, repeated blood tests were negative for HIV and hepatitis, meaning that the patient did not experience any long-term consequences.
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Table 1. Common Errors Occurring in Dialysis Units.
Incorrect dialyzer/dialysis solution/water quality issues |
- Transmission of infectious diseases
|
- Improper patient identification
|
|
Patient falls |
Medication errors and omission |
Nonadherence to procedures |
Vascular access-related events |
|
|
|
Table 2. Organizations Involved in Oversight of Patient Safety in Hemodialysis Units.
Centers for Medicare & Medicaid Services (CMS) |
Conditions of coverage include specific quality indicators. |
Surveyors from State Department of Health |
Can close units that do not meet standards of care. |
End-Stage Renal Disease (ESRD) Networks |
18 geographically organized committees under CMS supervision. Responsible for quality assurance and improvement in dialysis facilities within the network. Medical directors are given periodic assessments of unit morbidity and mortality compiled by the networks through CMS. |
United States Renal Data System (USRDS) |
A repository of data collected on each chronic dialysis patient covered under Medicare. An annual yearly report is published including special studies examining morbidity and mortality of dialysis. Data provided by USRDS may determine ESRD Network quality improvement projects and lead to development of standards of care. |
Association for the Advancement of Medical Instrumentation (AAMI) |
Sets standards for water quality, dialysate, and reuse procedures. |
Centers for Disease Control and Prevention (CDC) |
Sets standards for infection control in dialysis units and provides standards for indwelling catheter-associated infections. |
Table 3. Additional Factors in Oversight of Safety within Dialysis Facility.
Dialysis Facility |
Dialysis Facility Governing Body |
Dialysis Unit Medical Director |
- Interdisciplinary patient care team
|
- MD and nonphysician practitioners
|
- Nursing, dietary, social work
|
|
Dialysis Unit Manager |
Patients and dialysis unit staff |