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Last Updated 06/14/09
   

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In December 1999, the U.S. Federal Government's Institute of Medicine issued a report entitled, "To Err is Human: Building a Safer Health System". This report cited between 44,000 and 98,000 deaths every year due to medical errors. While these numbers are disputed by some, they would make medical errors the 8th leading cause of death, ahead of breast cancer or AIDS.

Dialysis patient safety is a complex issue that involves highly specialized dialysis technology, staff training and turnover, cost pressures, reporting of problems, oversight and regulations, water purification, dialyzer reuse, medication errors, patient compliance, patient education, primary care, prevention, vascular access, infection, location and layout of dialysis units, and the increased age and comorbidities of the ESRD population.

Patient safety and injury prevention are most effective when it involves everyone in the healthcare delivery scheme. Towards that end, RenalWEB has accumulated this list of resources that addresses safety issues from many perspective and at several different levels of complexity.

RenalWEB has a separate resource page for Infection Control.

Warning: Changes should never be made in a patient's treatment or care based solely on the information found here.  All patients have unique healthcare concerns and considerations and these must all be taken into account before any changes can be safely made.  All medical and therapeutic decisions must come from a qualified health care provider.  Read RenalWEB's Legal Disclaimer before proceeding.

  NEWS & LATEST ARTICLES
ANA Supports Safe Patient Handling Measures in Congress To Improve Safety of Nurses and Patients - Article (pdf) from the American Nurses Association (ANA). - June 10, 2009
FDA releases list of potential drug risks - Article from Yahoo!News. - June 4, 2009
Soap-Sniffing Technology Encourages Hand Washing To Reduce Hospital-Acquired Infections, Save Money - News release from University of Florida. - June 3, 2009
Commonly Used Medications May Produce Cognitive Impairment in Older Adults - News release from Indiana University. - June 1, 2009
Report Shows 10-Year Effort to Curb Medical Errors Yields Few Results - Articles from WebMD. - May 19, 2009
Safety Labeling Changes Approved By FDA for April 2009 - Included in the list are Extraneal (icodextrin) peritoneal dialysis solution and heparin. - May 19, 2009
Baxter Says Its Heparin Not To Blame for Injuries in Delaware - Article from Reuters. Press release from Baxter. - May 15, 2009
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  WEB RESOURCES
National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004 - (pdf format requires Adobe Acrobat Reader) from the National Center for Infectious Diseases (NCID)
ESRD Patient Safety Report (pdf format) - January 31, 2001 - from the Renal Physicians Association web site
Patient safety Network (PSNet) web site
Joint Commission International Center for Patient Safety web site
National Healthcare Safety Network (NHSN) - from the Centers for Disease Control and Prevention web site
2007 National Healthcare Quality & Disparities Reports - from the Agency for Healthcare Research and Quality (AHRQ)
National Patient Safety Agency web site (UK organization)
Keeping Kidney Patients Safe web site
Patient Safety Tools: Improving Safety at the Point of Care from the AHRQ web site
Working Together For Patient Safety - from the APP Pharmaceuticals web site
Using Human Factors Engineering to Improve Patient Safety - Association for Advancement of Medical Instrumentation (AAMI) web site. Cost is $70 for AAMI members / $80 nonmembers.
Promoting ESRD Patient Safety: For Caregivers - (requires Microsoft Word™) document from the ESRD Network 12 web site
Doctor-Robot Service - free online version of Medical Diagnostics Program Symptomat as a way to reduce medical errors
FDA Drug Safety Information for Patients and Health Care Professionals - from the U.S. Food and Drug Administration
FDA Video on Patient Safety Topics: Erythropoietic Agents and Antibody-Mediated Anemias - from the U. S. Food and Drug Administration
FDA Drug Safety Newsletter from the FDA/Center for Drug Evaluation and Research web site
Prevent Dangerous Hemodialysis Catheter Disconnections article from FDA's Medical Device Safety
Electrical Safety Manual, 2008: A Comprehensive Guide to Electrical Safety Standards for Healthcare Facilities - Association for Advancement of Medical Instrumentation (AAMI) web site. Cost is $85 for AAMI members / $135 nonmembers.
Preventing Falls Among Older Adults article from the Centers for Disease Control and Prevention web site
Protecting the Rights, Safety, and Welfare of Study Subjects - Supervisory Responsibilities of Investigators from the FDA's Regulatory Information
ANA Nursing Practice Information Infrastructure web site

Safe Practices for Better Healthcare - 2009 Update A Consensus Report 12-page (pdf) public version of the report from the National Quality Forum web site

Safe Staffing Saves Lives web site from the American Nurses Association (ANA)
Dialysis Collection of AAMI Dialysis Standards and Guidance Documents Revised for 2003 - Association for Advancement of Medical Instrumentation (AAMI) web site. Cost is $195 for AAMI members / $275 nonmembers.
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  ESSENTIALS AND CLASSICS
FDA Patient Safety News - video from the U. S. Food and Drug Administration - July 2006
Advances in Patient Safety: From Research to Implementation from the Agency for Healthcare Research and Quality (AHRQ) web site
Free Instructional Video: “Discussing Unanticipated Outcomes and Disclosing Medical Errors” from the Emory University Center for Ethics
First in a series of publications from the Institute of Medicine's Quality of Health Care in America project. To Err Is Human: Building a Safer Health System - on line book by Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine; Copyright © 2000.
Safe Patient Handling and Movement - from the U.S. Dept. of Veterans Affairs web site

Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project. Crossing the Quality Chasm: A New Health System for the 21st Century. Overview from the Renal Physicians Association web site

Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program - from the Centers for Disease Control and Prevention web site
Internal Bleeding: the Truth Behind America's Terrifying Epidemic of Medical Mistakes by Robert M. Wachter, MD and Kaveh G. Shojania, MD (Rugged Land Books, 2004)
ASHHRA Disaster Planning Guide - ($259 members/$329 nonmembers) from the American Society for Healthcare Human Resources Administration web site
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  PUBMED SEARCHES
PubMed Search Tool of the National Library Of Medicine's MEDLINE Database. These links allows you to search through over 11 million indexed articles. Due to copyright laws, only the abstracts (summaries) of the articles are usually listed. Some articles appear in full text on the publishers' web sites that are linked to PubMed. This page provides an Overview of PubMed. All these search results links are continually updated by the Library of Congress.
biocompatibility and dialysis
pyrogen and dialysis
equipment malfunction and dialysis
hemolysis and hemodialysis
chloramines and hemodialysis
disequilibrium syndrome and dialysis
dialysis dementia or dialysis encephalopathy
air embolism and dialysis
medical error and dialysis
patient safety and dialysis
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  DISCUSSION FORUM
General Dialysis Nursing Issues and Questions (No dedicated RenalWEB forum)
Dialysis Technical Forum  
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  RELATED TOPICS
AIDS (auto immune deficiency syndrome) and dialysis - PubMed search
VRE (vancomycin-resistant enterococci) and dialysis - PubMed search
MRSA (methicillin-resistant Staphylococcus aureus) and dialysis - PubMed search
Guidelines & Recommendations for Immunizations - infection control practices from the Centers for Disease Control and Prevention (CDC)
hepatitis AND dialysis - PubMed search - Continually Updated!
hepatitis B - PubMed search - Continually Updated!
hepatitis C - PubMed search - Continually Updated!
hepatitis AND vaccine - PubMed search - Continually Updated!
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  UPCOMING EVENTS
Listing of National Patient Safety Foundation Seminars
Listing of The American Health Quality Association Events Calendar
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  PRODUCTS
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  INPUT / SUGGESTIONS
E-mail to RenalWEB on the Hepatitis Topic
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