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Last Updated 09/10/17
   

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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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Safety and Efficacy of Polyurethane Vascular Grafts for Early Hemodialysis Access - Article in Press abstract from Journal of Vascular Surgery. - August 30, 2017

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Study Shows Nurses' Scrubs Become Contaminated with Bacteria in Hospitals - Press release from Society for Healthcare Epidemiology of America. - August 29, 2017

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Reframing the Opioid Epidemic as a National Emergency - Free, full-text, New Online viewpoint article from the Journal of the American Medical Association. - August 23, 2017

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FDA Recall Notices - August 15, 2017

  • Baxter HomeChoice Automated PD System Model Numbers: 5C4471, 5C4471R - 15,144 units
  • Baxter HomeChoice Pro Automated PD System Model Numbers: 5C8310, 5C8310R - 23,732 units

    Reason for recall: Baxter Healthcare Corporation has been made aware that users may not be following the instructions in the Operators Manual and incorrectly (using sharp objects) opening disposable set packaging while setting up their Peritoneal Dialysis (PD) therapy, damaging the cassettes for the HomeChoice or HomeChoice PRO cyclers. If damaged cassettes are used, the cyclers may not consistently detect very small holes/cuts in the sheeting of the cassette in the patient valve region and the cycler may deliver air into the patient
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Flimsy Evidence behind Many FDA Approvals - Article from Reuters. - August 15, 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

blue ball Risk Management - podcast from the Association for the Advancement of Medical Instrumentation (AAMI) web site
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.
blue ball Nephrologists Transforming Dialysis Safety (NTDS) - from the American Society of Nephrology web site
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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