By Alan S. Kliger, MD
Is your dialysis unit a safe place to be? Are you confidant that mistakes or mishaps will not happen, and that you will not be hurt?
We all see our doctors, and go to the hospital or medical facilities with the expectation that we will receive care to make our lives better. Fortunately, this is true most of the time. However, we now know that mistakes and unexpected events in hospitals and outpatient clinics occur all too often, causing harm and even death to thousands of Americans each year.
In 1999, the Institute of Medicine reported that as many as 98,000 Americans die each year in hospitals as the result of medical errors. Since that time, all hospitals have implemented new practices to improve patient safety. Most doctors, nurses and health care administrators have worked to 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 to find faulty systems of care and reduce errors.
These days, we do not have to go far to find evidence of mistakes that harm patients with kidney disease. In February 2003, a teenager from Mexico died after she mistakenly received a kidney transplant from a donor with a different blood type. 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. In 2001, blood stream infections were found in hemodialysis patients who had received contaminated erythropoietin injections.
Several years ago, the Renal Physicians Association (RPA), the Forum of End-Stage Renal Disease Networks (Forum) and the National Patient Safety Foundation spearheaded a national effort to understand the causes of medial errors and patient safety problems in dialysis units. The large dialysis organizations identified several areas of concern, including patient falls, medication errors, vascular access-related events, dialyzer errors, excess blood loss and prolonged bleeding. Since that time, many dialysis units have taken initiatives to reduce these problems. For example, a dialysis facility in Wheeling, W.V., conducts fall risk assessments for all patients and gives focused educational programs for patients, caregivers and staff to reduce falls. Physical therapists assist patients with physical strengthening exercises, and physicians are notified of falls at home so dialysis heparinization can be adjusted. In other facilities, pharmacists on rounding teams have been shown to reduce preventable adverse drug events. Research in the safety sciences has shown that process design in the dialysis facility must be reviewed to improve safety.
Dialysis facility owners and staff are asked to:
AAKP now is working with the RPA and Forum to find ways to improve patient safety in dialysis units. In the next few months, a national questionnaire will be offered to dialysis patients to define what patients find as safety concerns and medical errors. In addition, dialysis doctors, nurses, staff and administrators will be invited to fill out a similar questionnaire on the Internet. We then hope to share our solutions to problems raised; facilities that have found solutions to these problems can share their “best practices” with all others on a Web-based interchange of best practices. We need to learn from one another to improve safety.
Patients play a critical role in the process of improving safety. One of the greatest sources of errors is in medication prescription and administration. Most dialysis patients use many different medications, often prescribed by different physicians and specialists. With many medications of different strengths, taken at different times of the day and for different reasons, it is clear that dose mistakes or incompatibility of some medications are common in dialysis patients. This risk is particularly high when patients are admitted to or discharged from hospitals, as well as when new medications, different instructions, or changing medical conditions make the correct medication list difficult to construct. Patients can help ensure their own safety by always keeping a list of medications and updating that list when medicines or doses change.
A national program, 5 Steps to Safer Health Care, urges patients to:
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Speak up if you have questions or concerns.
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Keep a list of all your medications.
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Make sure you get the results of any test or procedures.
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Talk with your doctor and health care team about your options.
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Make sure you understand what will happen if you need surgery.
Ask your doctor and healthcare team about safety efforts in your dialysis unit. Is there a culture of safety where patients and staff are encouraged to report mistakes, adverse events and “near-misses” in a non-punitive atmosphere, where fingers of blame will not be pointed but action will be taken to improve systems of care? Is there a program to reduce falls and to regularly review medications and avoid bad drug interactions? If dialyzers are reused, what systems are in place to prevent wrong patient assignments to dialyzers? Have processes of care been reviewed to simplify and standardize? Are checklists used? Are you doing your part to ensure your safety?
Alan S. Kliger, MD, is clinical professor of medicine at Yale University School of Medicine, and chairman of the Department of Medicine, Hospital of St. Raphael, New Haven, Conn. He also serves on the Board of Directors of the Renal Physicians Association.
This article originally appeared in the September 2005 issue of aakpRENALIFE, Vol. 21, No. 2.
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