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Last Updated 10/22/17
   

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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

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The Hurricane in Puerto Rico Is Leading a Shortage in Saline Bags - Posting from the KevinMD blog. News brief from AHANews. - October 17, 2017

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The Health Care Professional's Pledge: Protecting Our Patients From Firearm Injury - Free, full-text, Latest editorial from Annals of Internal Medicine. - October 17, 2017

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Pharma's Puerto Rico Problems Could Mean Drug Shortages: FDA Chief - Article from Reuters. - October 10, 2017

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Group Offers Guidance for Engaging New Clinicians in Patient Safety - News Brief from AHANews. - October 6, 2017

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Saline Supply Hamstrung by Puerto Rico Disaster - (Registration required, but free.) Article from Modern Healthcare. News summary from Kaiser Health News. - October 4, 2017

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Blood Thinners Can Come With Dangerous Side Effects - Article from HealthDay. - October 3, 2017

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Poor Leadership and Disastrous Decision-Making Are to Blame for Florida's Nursing Home Deaths - Posting from the KevinMD blog. - October 2, 2017

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Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes — A Cluster-Randomized Trial - New Online abstract from JAMA Internal Medicine. - October 2, 2017

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FDA Improves Access to Reports of Adverse Drug Reactions - September 28, 2017

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Increased Mortality in Hemodialysis Patients Administered High Doses of Erythropoiesis-Stimulating Agents: a Propensity Score-Matched Analysis - Advance Article abstract from NDT. - September 28, 2017

Editor's note: Remember this Boston Globe article from 2006? The last two paragraphs tell one of many tragedies of for-profit, junk-bond nephrology.

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FDA Acts to Prevent Shortages of Drugs Made in Puerto Rico - AHANews news brief. FDA statement. - September 26, 2017

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FDA Recall Notice: Baxter Amia Automated Peritoneal Dialysis Set with Cassette - Recall was initiated Sept. 1, 2017 for 164,700 units. - September 14, 2017

"The firm received increased customer complaints for Missing Red Line, Patient Slow Flow, Solution Slow Flow, and Inadequate Drain alerts on certain lots of the AMIA Automated Peritoneal Dialysis Set with Cassette."

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FDA Approval of Nonadjunctive Use of Continuous Glucose Monitors for Insulin Dosing — A Potentially Risky Decision - Free, full-text, New Online viewpoint article from the Journal of the American Medical Association. - September 14, 2017

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Nurses' Regular Use of Disinfectants Is Associated with Developing COPD - News release from European Lung Foundation. - September 10, 2017

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  WEB RESOURCES

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Safe Patient Handling from the American Nurses Association (ANA)
5-Diamond Patient Safety Program - 15 module program from the Mid-Atlantic Renal Coalition (Network 5) and the 2014-2015 5-Diamond Data Book
AAMI Standards and Recommended Practices: Dialysis 2015 edition - The 2015 collection consists of 11 AAMI Hemodialysis standards, six of which were published in 2014 (Price Mbr/List $357/$541)
Dialysis Event Protocol (pdf) and Tables of Instructions (pdf). - updated June 2011 from the National Healthcare Safety Network (NHSN)
Electrical Safety Manual - 2015 Edition: A Comprehensive Guide to Electrical Safety Standards for Healthcare Facilities - Association for Advancement of Medical Instrumentation (AAMI) web site. Cost is $117 forAAMI members / $195 nonmembers.
FDA Drug Safety Information for Patients and Health Care Professionals - from the U.S. Food and Drug Administration
Healthy People 2010 Final Review and chapter 4 on Chronic Kidney Disease (12-page pdf). - from the U.S. Department of Health and Human Services (HHS)

IAC Publications: Needle Tips - from the Immunization Action Coalition

Improving Patient Safety in Long-Term Care Facilities - Resources from the Agency for Healthcare Research and Quality. 

Joint Commission International Center for Patient Safety web site
Keeping Kidney Patients Safe web site

National Healthcare Safety Network (NHSN) Dialysis Event Protocol - 6-page pdf from the Centers for Disease Control and Prevention web site. NHSN Dialysis Event website. -
Also see:
Patient Safety Monthly Reporting Plan (2-page pdf)
Patient Safety Component -- Outpatient Dialysis Center Practices Survey (6-page pdf)

National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004 - (pdf) from the National Center for Infectious Diseases
National Patient Safety Agency web site (UK organization)
Nephrology Nursing Scope and Standards of Practice © 2011 (7th Edition)  - from the American Nephrology Nurses Association web site
One Needle, One Syringe, Only One Time - A new educational video for healthcare providers on safe injection practices from the One & Only Campaign
Patient safety Network (PSNet) web site
Preventing Bloodstream Infection During Hemodialysis - Video from the CDC Dialysis Bloodstream Infection Prevention Collaborative is sponsored by the Centers for Disease Control and Prevention (CDC) and conducted in partnership with the Delmarva Foundation and others.
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 (pdf) from the FDA's Regulatory Information

Renal Patient Safety Resources+ - List from the Renal Physicians Association web site. - July 2010

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Safe Staffing Saves Lives web site from the American Nurses Association (ANA)
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  ESSENTIALS AND CLASSICS

Dialysis Safety - from the Centers for Disease Control and Prevention (CDC) web site
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.
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Safe Patient Handling and Movement - from the U.S. Dept. of Veterans Affairs web site
Patient Safety: Safe Practices 2010 from the National Quality Forum (NQF) 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.

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)
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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 Events & Forums
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  PRODUCTS

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  INPUT / SUGGESTIONS

E-mail to RenalWEB on the Hepatitis Topic
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