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Patient safety in hemodialysis care delivery - a commentary.

Hemodialysis, like other invasive health care treatments, is not without its risks. Patient care incidents and events are numerous and commonly seen and reported through event tracking mechanisms specific to individual programs or institutions. Examples of reportable incidents include medication errors (wrong patient, wrong medication, wrong dose, wrong time), breach of infection control practices, errors in dialysate composition, falls, and more. Quality assurance (QA) or Continuous quality improvement (CQI) programs are often an integral part of hemodialysis units yet, despite improvements, incidents and errors continue to be reported. Pressures related to time and staffing appear to have exacerbated the problem, leading to staff and administrative concern about this important issue (Tregunno et al., 2009).

Numerous nursing-focused studies have been carried out that have demonstrated the impact of near misses and patient-level incidents related to patient health care. For example, Tregunno et al. (2009) conducted focus groups with direct care providers (nurses) and nursing leaders to examine the role of the latter in the prevention of patient-level errors. They revealed the need for a culture of safety--as defined by the nursing leader--that supports incident reporting while at the same time encouraging discussion without any fear of repercussions. The focus here is on using incidents and errors as opportunities for improvement and for learning, and not for blame.

Moreover, near misses in health care have been described both as proactive opportunities (to avoid error) and as recovery processes--an opportunity to change nursing care delivery in order to avoid a negative outcome. For example, Jeffs, MacMillan and Maione (2009) describe that screening for, detection of, and management of early stage pressure ulcers can be viewed as near misses since avoidance strategies or adjustments to nursing care can prevent complications such as pain, infection, and even death. In this case, prevention of the complications equates to avoidance of patient level incidents or errors.

In another study, Jeffs, Affonso and MacMillan (2008) explored the experiences and perceptions of health care providers (nurses and pharmacists) and health care consumers about near misses in patient care and what contributes to their occurrence. This qualitative analysis revealed a number of themes that were commonly found in participants' dialogue in the focus group setting. Amongst other findings, they identified that "Collectively, the current complex and acute nature of the health care system coupled with the demands put on the health care team increase the potential for near misses and errors to occur" (p. 491). Worldwide, there has been a strong academic focus on the subject of health care and safety. Numerous resources exist to assist us in providing quality, safe patient care. For example, organizations such as the World Health Organization (WHO) have provided guidelines for prevention of errors in health care. Their Conceptual Framework for the International Classification for Patient Safety, created in 2009, provides tools that facilitate incident reporting through standardized definitions and organized template development based on the existing literature. The WHO document is intended to standardize safety concepts in health care and facilitate reporting, analysis, and interpretation of information in an effort to improve outcomes in patient care. More locally, the Canadian Patient Safety Institute (CPSI) has recognized the importance of education for health care professionals about patient safety and their role in prevention of health care-related errors. Their "Safety Competencies Framework" provides "a simple, powerful, and flexible framework that could be integrated smoothly into curricula at educational institutions, adopted by health care associations and directly applied in patient care sites across the spectrum of health care delivery" (Frank & Brien, 2008, p. 2). The CPSI also delivers the "Safer Healthcare Now!" program, which focuses on frontline providers and the health care delivery system by providing education and tools for improving patient safety throughout Canada. These tools and resources can be found at their website

From a medication safety perspective, the Institute for Safe Medication Practices (ISMP) was established in 1975 with a regular journal column that educated and informed readers about the prevention of medication errors. ISMP is now a world-renowned organization that advises in an impartial manner about medication safety practices. Their website ( contains information, tools, reporting forms, access to webinars, and safety alert newsletters. The ISMP will also carry out consultations to organizations that are interested in a review of systems and processes with a view to reduce potential for errors.

How safely do we deliver hemodialysis? Besides CQI or QA programs, we use checklists to verify machine settings during setup, and have regular equipment checks and calibrations done by our technological colleagues. In fact, over the years, hemodialysis has become more complex and sophisticated and, coincidentally, has evolved to be more strictly regulated and managed from a technological perspective in order to improve safety and mitigate risk. For example, air detector monitors, online conductivity monitoring, and blood circuit pressure gauges (arterial and venous pressure monitors) have all come to exist by way of necessity and as a result of patient incidents. The age-old adage resonates here--we learn from our mistakes. Early on, hemodialysis equipment was not regulated by standards and manufacturing guidelines. Nowadays, however, hemodialysis equipment must conform to Canadian Standards Association (CSA) standards that describe and mandate appropriate parameters for water used for hemodialysis, concentrates used in delivery of hemodialysis, and dialyzer reuse to name a few. According to the CSA, their standards in health care "help protect patients and workers in the health care system by setting minimum requirements for safety in medical devices, buildings, systems, and management of professional practices." They also "increase efficiency in health care facilities and systems without compromising patient care" (n.d.). Our technologist colleagues can attest to and educate us on these standards and their meaning to the everyday practice of maintaining hemodialysis equipment and water treatment systems, along with numerous other pieces of equipment for which they are responsible.

Despite the regulated technological standards that are intended to keep our patients safe, patient care examples of near misses or incidents are numerous in hemodialysis settings. Consider these scenarios:

Scenario A: Patient A.J. has been ordered to have predialysis lab work done today. When the RN goes to search the computer for the results, she cannot find any evidence that blood has been received in the lab. Shortly thereafter, J.J.'s RN receives a call from the laboratory advising her of a low hemoglobin level on her patient from a sample sent predialysis today. She is puzzled, since she did not draw any lab work on J.J. when initiating his hemodialysis treatment. Coincidentally, A.J. and J.J have similar surnames and it is presumed that there has been a mix-up in labelling, either in the hemodialysis unit, or in the laboratory.

Scenario B: Maria is looking after M.R. today. She has been ordered to receive an intravenous dose of iron every two weeks on hemodialysis. When reviewing M.R.'s chart postdialysis, Maria notices that she inadvertently omitted the dose of intravenous iron today. She revises the schedule to ensure that the dose will be delivered at the next hemodialysis session.

Scenario C: Patient S.T. reports to the chair for his hemodialysis and indicates his predialysis weight to Jane as 74.5 kg. Jane jots down the number, and is called away to the desk. Robert returns from lunch break and initiates S.T.'s hemodialysis treatment. About two hours into the treatment, S.T. becomes severely hypotensive with bilateral leg cramping. A normal saline bolus and reduction in ultrafiltration rate are required to resolve the symptoms. On review of the situation, Jane and Robert discover that Robert misread Jane's handwriting and had set the target fluid loss at 2 kg higher than the actual target required to achieve S.T.'s desired postdialysis target weight.

The scenarios are probably not foreign to hemodialysis staff. However you would define these, as either near misses or adverse events, these are potentially avoidable missteps in delivery of care. Dr. Alan S. Kliger described the challenge in a web-based conference hosted by the ECRI institute in 2008 as follows: "Mistakes are common ... and are part of our daily lives. The conundrum is that when admitted to ... a dialysis unit, we expect no mistakes. ... so the real challenge is to figure out how you bridge that gap" (as quoted in Hogan, 2008).

Kliger and his American colleagues at the Renal Physician's Association and the Kidney & Urology Association of America, Inc. surveyed patients and professionals in nephrology in 2006-2007 about their experiences with errors in nephrology settings. Errors were commented on in categories such as hand washing, needle insertion, medication errors, predialysis setup, and falls. Results of the survey showed that 87% of professionals reported errors had occurred in their centres within the previous three-month period--and that 59% of those errors were attributed to lack of adherence to unit procedures. Twentyseven per cent of patients reported having witnessed a mistake within the previous three months, and 49% said they worried about a mistake being made related to their treatment (Hogan, 2008). These are sobering statistics.

What can we do? Acknowledging the problem is the first step. Taking measures to improve the culture of safety at both leadership and direct care levels is also needed. QA or CQI initiatives are clearly important--but we need to do more. Reviewing unit processes and reducing pressure on staff that is either self-imposed or imposed by anxious patients who are keen to get their treatment underway is also important. Review of documentation tools for clarity and ease of use, use of electronic charting programs, and use of incident reports as educational opportunities are additional ways of improving outcomes and reducing risk. Many operating rooms are now using surgical safety checklists prior to initiating any procedures. This initiative not only involves staff, but also involves the patient as part of the health care team. The "surgical pause" could be a tool revised for use to slow down the busy hemodialysis team and potentially prevent setup and initiation errors in hemodialysis patient care.

Finally, researchers have called for efforts--both organizational and professional--to support nurses engaging in research projects that advance patient safety practices in clinical settings (Jeffs et al., 2009). It is time to address some of the more commonly occurring incidents in hemodialysis care and try to come up with alternative methods to prevent these incidents. As nurses, we have the patients' interests at heart--and their safety in our hands. I challenge you to think outside the box for ways in which you can improve patient care outcomes in your own hemodialysis units. Why not start today?


About ISMP. (n.d.). Institute For Safe Medication Practices. Retrieved from

Conceptual Framework for the International Classification for Patient Safety. (n.d.). World Health Organization. Retrieved from

Frank, J., & Brien, S. (2008). The Safety Competencies: Enhancing Patient Safety Across the Health Professions. Ottawa: Canadian Patient Safety Institute.

Health Care | Standards | CSA. (n.d.). CSA Standards. Retrieved from

Hogan, M. (2008). Dialysis safety a hallenge, but practical changes can help. Nephrology Times, 1(9), 1.

Jeffs, L., Smith, O.M., Wilson, G., Kohn, M., Campbell, H., Maione, M., et al. (2009). Building knowledge for safer care: Nursing research advancing practice. Journal of Nursing Care Quality, 24(3), 257-262.

Jeffs, L., Affonso, D.D., & MacMillan, K. (2008). Near misses: Paradoxical realities in everyday nursing practice. International Journal of Nursing Practice, 14, 486-494.

Jeffs, L., MacMillan, K., & Maione, M. (2009). Leveraging safer nursing care by conceptualizing near misses as recovery processes. Journal of Nursing Care Quality, 24(2), 166-171.

Tregunno, D., Baker, R., Jeffs, L., Doran, D., Hall, L.M., & Bassett, S.B. (2009). On the ball: Leadership for patient safety and learning in critical care. Journal of Nursing Administration, 39(7/8), 334-339.

Address correspondence to: Alison Thomas, RN(EC), MN, CNeph(C), Nurse Practitioner--Adult, Hemodialysis, St.Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8. E-mail:

Department Editor: Eleanor Ravenscroft, RN, PhD, CNeph(C)
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Title Annotation:Practice corner
Author:Thomas, Alison
Publication:CANNT Journal
Article Type:Viewpoint essay
Date:Jul 1, 2011
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