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Last Updated 5/12/13
   

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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

FDA Product Class II Recall Notices in May 8th Enforcement Report - May 8, 2013
• Diacap(R) Ultra Dialysis Fluid Filter (9 lot numbers) - B Braun
• NxStage PureFlow-B Solution, Model/Catalog Number: RFP-401 (1480 cases) - NxStage

iPads Could Affect Implanted Heart Devices, Early Study Finds - Article from HealthDay. Swimming pools, too. - May 9, 2013

Doctors' Diagnostic Errors Are Often Not Mentioned But Can Take A Serious Toll - Article from Kaiser Health News and The Washington Post. - May 6, 2013
"Diagnoses that are missed, incorrect or delayed are believed to affect 10 to 20 percent of cases, far exceeding drug errors and surgery on the wrong patient or body part, both of which have received considerably more attention."
Editor's note: Perhaps what we need is a new diagnosis — "failing to thrive" for adult dialysis patients. That would force nephrologists to provide the care they would want for themselves and their own family members.

FDA Limits Duration and Usage of Samsca (tolvaptan) Due to Possible Liver Injury - An FDA Drug Safety Communication.  - April 30, 2013

Abbott Recalls Defective Glucose Meters - April 15, 2013

March 2013 FDA Safety Labeling Changes - List includes 53 products with revisions to prescribing information. - April 15, 2013

Top 10 Ways to Improve Patient Safety Now - Article from American Medical News. - April 15, 2013
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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)
AAMI Standards and Recommended Practices: Dialysis 2012 edition- This comprehensive dialysis collection includes EVERY CURRENT AAMI HEMODIALYSIS standard and guidance document; including Updated to include the 2012 edition of 60601-2-16, the 2013 collection includes all 10 AAMI dialysis standards. Other recently updates have included TIR43 (revises RD52) and five other standards were published in 2011, including 11663 and 23500 (revise RD52), 13958 (revises RD61), 26722 (revises RD62) and 13959 (Price Mbr/List $260/$430)
Dialysis Event Protocol (pdf) and Tables of Instructions (pdf). - updated June 2011 from the National Healthcare Safety Network (NHSN)
Doctor-Robot Service - free online version of Medical Diagnostics Program Symptomat as a way to reduce medical errors
Electrical Safety Manual - 2013 Edition: A Comprehensive Guide to Electrical Safety Standards for Healthcare Facilities - Association for Advancement of Medical Instrumentation (AAMI) web site. Cost is $90 forAAMI members / $160 nonmembers.
ESRD Patient Safety Report phase 1 and phase 2 (pdf format) - December 1, 2001 - from the Renal Physicians Association web site
FDA Drug Safety Information for Patients and Health Care Professionals - from the U.S. Food and Drug Administration
FDA Drug Safety Newsletter from the FDA/Center for Drug Evaluation and Research web site
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)
Hemodialysis Administration: Strategies to Ensure Safe Patient Care - From the Sept. 2010 report from the PA Patient Safety Authority. - September 2010

IAC Publications: Needle Tips - from the Immunization Action Coalition
Joint Commission International Center for Patient Safety web site
Keeping Kidney Patients Safe 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.

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)
National Prevention Council: National Prevention Strategy To Promote Health and Prevent Disease and Disabilities from Healthcare.gov web site - June 2011
One Needle, One Syringe, Only One Time - A new educational video for healthcare providers on safe injection practices from the One & Only Campaign
Nephrology Nursing Scope and Standards of Practice © 2011 (7th Edition)  - from the American Nephrology Nurses Association web site
Patient safety Network (PSNet) web site
Patient Safety Tools: Improving Safety at the Point of Care from the AHRQ web site
Prevent Dangerous Hemodialysis Catheter Disconnections article from FDA's Medical Device Safety
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

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

Safe Practices for Better Healthcare - 2010 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)

There and Home Again, Safely - 5 Responsibilities of Ambulatory Practices
in High Quality Care Transitions from the AMA web site
Working Together For Patient Safety - from the APP Pharmaceuticals web site
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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.
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 Events & Forums
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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