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Last Updated 07/11/10
   

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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
Take Rosiglitazone (Avandia) Off the Market, Says FDA Staff - Articles from MedPage Today and HealthDay. Additional article from MedPage Today. - July 9, 2010
FDA Warning: No Quinine for Leg Cramps - Safety notice from the U.S. Food and Drug Administration. - July 8, 2010
FDA Issues Warning on Weight Loss Supplement Que She - Article from Health News. - July 8, 2010
FDA Class I (Highest Risk) Recall: LIFEPAK 20 and LIFEPAK 20e External Defibrillator/Monitors by Physio-Control - Recall notice from the U.S. Food and Drug Administration. - July 2, 2010
A Successful Approach to Fall Prevention in an Outpatient Hemodialysis Center - CJASN Express abstract. - July 1, 2010
FDA Warns Baxter On Failures To Properly Report, Investigate Dialysis Device Problems - Reuters news item. June 3rd warning letter from the FDA. - June 29, 2010
ADA: Glucose Monitors Lack Uniformity - Article from MedPage Today. - June 29, 2010
UK Issues Medical Device Alert for All 5008 & 5008S Hemodialysis Machines Manufactured by Fresenius Medical Care AG - June 28, 2010
Notice from the UK Medicines and Healthcare Products Regulatory Agency. An electronic component may fail and cause the visual screen display of the haemodialysis machine to ‘black out’. The touch screen may still remain active/touch sensitive despite the visual screen failure.
FDA: Cardiovascular and Renal Drugs Advisory Committee Meeting Announcement - The July 29th meeting will discuss Revatio (sildenafil) for the treatment of pediatric pulmonary arterial hypertension. - June 25, 2010
Tamiflu: Counterfeit Product Sold on Internet - Safety notice from the U.S. Food and Drug Administration. - June 17, 2010
Defibtech DBP-2800 Battery Packs used in Lifeline AED and ReviveR AED: Recall - Recall notice from the U.S. Food and Drug Administration. - June 14, 2010
Patient Safety: What Can Medicine Learn from Aviation? - Article from American Medical News. - June 14, 2010
FDA Drug Safety Communication: Ongoing safety review of Benicar and cardiovascular events - Safety announcement from the U.S. Food and Drug Administration. - June 11, 2010
Recall of Additional Cipro Brands - Summary from the NW Renal Network. - June 10, 2010
One Needle, One Syringe, Only One Time - A new educational video for healthcare providers on safe injection practices from the One & Only Campaign. - June 2010
Class I Recall of Defibtech ReviveR AED™ and Lifeline AED Defibrillator Battery Packs - Notice from the FDA. - May 21, 2010
FDA Warning Letter to Artegraft, Inc. - They are manufacturers of Artegraft (vascular graft) and D-Clot (thrombectomy catheter system). - May 11, 2010
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  WEB RESOURCES
ANA Safe Patient Handling web site from the American Nurses Association (ANA)
5-Diamond Patient Safety Program - 12 module program from the Mid-Atlantic Renal Coalition (Network 5)
Dialysis Event Protocol (pdf) and Tables of Instructions (pdf). - updated February 2010 from the National Healthcare Safety Network (NHSN)
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 phase 1 and phase 2 (pdf format) - December 1, 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.
One Needle, One Syringe, Only One Time - A new educational video for healthcare providers on safe injection practices from the One & Only Campaign
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
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
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. 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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