INVESTIGATION INTO SAFETY MANAGEMENT OF MEDICAL HAEMODIALYSIS

Submitted to: Dr Graham Richard Submitted by: Md. Nazmul Hoque. S.I.D: S104R0153 Submitted date: 11th of December

Acknowledgement
Medical mistakes that harm patients have occurred in dialysis facilities, just as they have been reported to cause death in hospitals. A plan to recognize and prevent mistakes includes several elements. (1) Establish a culture of safety, where safe practices are a priority and reporting of adverse events and 'near misses' is encouraged in a non-punitive environment. (2) Redesign processes of care to minimize patient falls, medication errors, bleeding from vascular accesses, dialyzer reuse errors and other problems. (3) Perform root cause analyses of adverse events and 'near misses'. (4) Involve patients in safety efforts, including maintaining an accurate, up-to-date medication list. (5) Dialysis facilities should function as high-reliability organizations, focusing on the possibility of failures, expecting to make errors, training to recognize and recover from them and making system reforms following root cause analyses. In 1999, the Institute of Medicine reported that as many as 98,000 Americans die each year in hospitals as the result of medical errors. Since that time, all hospitals have implemented new practices to improve patient safety. Most doctors, nurses and health care administrators have worked to establish a culture of safety, where safe practices are a priority and reporting of adverse events and near misses is encouraged in a non-punitive environment to find faulty systems of care and reduce errors. These days, we do not have to go far to find evidence of mistakes that harm patients with kidney disease. In February 2003, a teenager from Mexico died after she mistakenly received a kidney transplant from a donor with a different blood type. In June 2004, hundreds of patients in British Columbia, Canada were tested for hepatitis after several dialysis machines were found to have leaks, potentially exposing patients to the blood of others who had been dialyzed on that same machine. In 2001, blood stream infections were found in hemodialysis patients who had received contaminated erythropoietin injections.

Contents
Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 pg 4 pg 7 pg 8 pg 10 pg 11 pg 18

Chapter 1: Background
In 1987, two hospitals of UK reported that two medical incidents in which nursing staff inadvertently connected patient electrocardiogram (ECG) lead wires to the main supply power. As a result, these patients received electric shocks. One incident resulted in death by electrocution; and the other one made severe thirddegree burns that need to undergo plastic surgery. The cause for the hazard was investigated because of inappropriate connection of two medical device componentsunprotected patient electrode lead wires and detachable device line cords. (MDSR, 1987) More severity, August 20, 1998 in Hong Kong, three dialysis patients were killed and three patients were admitted to Intensive Care Unit (ICU ) with a critical ill involving a medical incident, which occurred in the Renal Dialysis Unit of the Hong Kong Sanatorium and Hospital. At the very beginning of haemodialysis on that day, the patient started to vomit and shake one by one. Not until the haemodialysis machine alarm responded, the nurse stopped the machine. Unfortunately, it seems to be too late! It is said that the patients started to feel uncomfortable however these patients were ignored by the nursing staff there. After that, one Investigation Team of the Department of Health found the incident was happened from contamination of the water treatment system used for haemodialysis and a multitude of factors acted together to result in this event. The water was thought to be cleaning fluid, but it pumped through an undermaintenance kidney dialysis machine. In fact, the report highlighted that if more supervision was paid to the operation of the machine as well as the one who operates it, the accident might be avoided! The above two stories quoted as examples, patient safety is a serious global public health issue. World Health Organization (WHO) estimates that tens of millions of patients worldwide suffer to injure or death from medical error each year due to unsafe medical practices and care. In developing countries, the probability of patients being harmed in hospitals is higher than in industrialized nations. At least 50 of medical equipment in developing countries is unusable or only partly usable in view of the equipment is not often used due to lack of popper training or skill. As result, diagnostic procedures or treatments cannot be performed. This leads to substandard or hazardous diagnosis or treatment that can pose a threat to the safety of patients and may result in serious injury or death. The economic benefits of improving patient safety are compelling. In 1999 USA, the Institute of Medicine (IOM) of the National Academy of Sciences released a report, To Err is Human: Building a Safer Health System.The report stated that medical errors result in the deaths of about 98,000 people every year. Even using the lowest estimate, this would make medical errors the eighth leading cause of death in the UShigher than motor vehicle accidents, breast cancer, or AIDS. The report estimates that medical errors cost the US approximately $37.6 billion each year. The costs associated with preventable errors are estimated to be between US$17 and $29 billion. The report also discussed the scale of medical errors arising from poor device design,
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based on an extensive review of medical error data and interviews with device developers. In Canada, between 1987 and March 2003, Health Department received reports of 425 separate incidents involving infusion pumps. Of the 425 incidents, 23 resulted in death, 135 resulted in injury, and 127 could potentially have led to death or injury. In the UK the situation is similar. According to the Medical Devices Agency of UK (MDA, 1999), over 66,000 adverse incidents involving medical devices were reported. It included 87 deaths and 345 serious injuries. Furthermore, in the five years to 2007, there are received 530 adverse incidents relating to dialysis machines and their associated equipment and disposables. Another, in the Australian Incident Monitoring Study reported that 177 incidents were due to "pure" equipment failure according to pre-defined criteria. The report estimated 107 (60%) involved anesthetic equipment, 42 (24%) involved monitors, 17 (10%) other theatre equipment and 11 (6%) the gas or electricity supply. Ninety-seven (55% of the 177) were potentially life-threatening. Studies show that additional hospitalization, litigation costs, infections acquired in hospitals, lost income, disability and medical expenses have cost some countries between US 6 billion and US 29 billion a year. Nowadays, due to technological advances, medical devices play an increasingly important role in the healthcare organizations; the public gradually expresses concern over the safety use of medical devices. These data are truly shocking. There is a heightened awareness among all healthcare professionals. The safe use of medical device is an important component of many patient safety initiatives. It is reflected in the credo first do no harm shared by all medical and allied health professionals. Nowadays, healthcare professionals should take a period of considerable change in their attitude towards medical error and their understanding of its causes. Haemodialysis in Hong Kong While the treatment of End Stage Renal Disease is one of the tremendous success stories of modern medicine, medical mistakes that harm patients have occurred in renal dialysis unit as well; just they have been report to cause death in Hong Kong hospital., Nowadays, Hong Kong people have been given attention to the occurrence of medical errors and concerned with patient safety. There are many researches and approaches to explore the safe use of medication and the quality assurance in surgical operation from other countries. However, there are few researches to assess the safe use of high risk medical devices in dialysis facilities although some of health care professionals, patients, and others are aware of cases of error in this field, perhaps most notoriously during hemodialysis. Furthermore, despite efforts of the Medical Devices Control Office, which issues safety warnings, adverse incidents with medical devices continue to occur, some of which result in serious injury or death through device failures, user errors, and organisational problems .In addition, the Hospital Authority of Hong Kong is perceived to have a poor record of medical incidents. For instances, there are few data on staffs competence audit in using high risk equipment; no consistent
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guideline on the safe use and maintenance of medical equipment; no popper hospital-wide monitoring system on the safe use of medical equipment, and no details of data on patient incidents due to unsafe use of medical equipment. Because so many problems occurred, ranging in severity from insignificant to catastrophic, it is important to select the patient safety problems for analysis, especially, equipment safety is a crucial factor of good patient care in the hemodialysis process. Owing to the hemodialysis population in Hong Kong keeps increasing these years, we should paid more attention to patient safety with the growing hemodialysis population.

Chapter 2: Aim
This study may be used to help mention these problems in a structured way, with the intent of preventing their recurrence. To address the challenge of improving dialysis patient safety regarding to use of high risk medical devices; this paper initiates a study to address these issues. The Aim of Study as below: Analyses of the high risk medical device incidents to explore the background conditions as well as the triggering factors and unsafe actions. To help prevent repetitions and contribute to an open supportive environment. Developing Continuous Quality Improvement on safe use of medical devices hazard in Renal Dialysis Centers. Structure of Thesis This paper presents the results of an investigation into medical errors in the UK and the USA, and focuses in particular on the magnitude and causes of errors when using medical devices. Contrary to the traditional approach of blaming users, it is suggested here that many such errors are caused partly by poor device design, which fails to account adequately for the needs of users. In response, this paper also discusses the basics of a Human Factors Engineering (HFE) approach as a step towards overcoming this problem and offers a challenge to device users and design companies (manufacturers) to follow HFE principles in order to improve the efficiency of operation and reduce errors during device use.

Chapter 3: Literature Review

The purpose of this review is to provide a framework for viewing success and its measurement in quality and safety management of device related to medical error, and, specifically, to examine the causes influence successful management outcomes. The literature review that follows is organized the main sections intended to address the following research questions:

What are the definition of patient safety and medical error in health care? What is the relation between haemodialysis and patient safety at a renal dialysis centre? What are the current system to assess the safety, effectiveness and quality of medical devices to safeguard patient health? How is success defined in safety management? Specifically, how do patient define success? What factors are involved in safety management in a dialysis center success? How do the different quality improvement approaches to reduce errors? How should we manage the high risk medical devices in a dialysis center?

The literature review will consist of four primary sections. The first section will focus on the challenge of patient safety. The second section will review the interrelationships between haemodialysis and patient safety. The third section will examine and discuss the current practice and solutions on critical issues in managing change. The fourth section will discuss various quality improvement approaches to reduce errors. Document Records Patient Safety Maintainer Control System Device Design Management of High Risk Medical Devices Dialysis Center Management Approaches Medical Devices Classification Staff Training User Government Regulation Medical Incident Customer Education
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Medical device, many people tend to describe that complex, highly technical equipment used in acute healthcare facilities. However, medical devices cover a broad range of products, including highly complex and sophisticated products such as Magnetic Resonance Imaging System to simple products such as bandages and thermometers. By the classification rules of the MDACS, medical devices are classified into four categories (Class I to IV) According to their risk levels, Class IV being the category of the highest risk and Class I the lowest.

Chapter 4: Methodology
Research is an important tool for improving patient safety which contributes to a better understanding of the extent and causes of unsafe care, as well as developing and evaluating the impact of solutions on reducing patient harm. The Research Programme was set up by the WHO World Alliance for Patient Safety to foster research for patient safety worldwide and help foster the development of national patient safety research agendas. WHO has formulated an expert working group in this concern?

Research Question Select Search Terms Select Inclusion & Exclusion Criteria Analysis Research Findings Conclusion

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CHAPTER 5: Analysis A survey of large dialysis organizations conducted by the Renal Physicians Association, the Forum of End- Stage Renal Disease Networks and the National Patient Safety Foundation identified several safety problems in dialysis facilities: patient falls, medication errors, vascular access-related events, dialyzer errors, excess blood loss and prolonged bleeding. Several highly publicized cases of medical mistakes in dialysis and transplant patients underscore the need for the end-stage renal disease community to deal with this troubling problem. In one hemodialysis center, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions resulted from puncturing single-use vials of epoetin-multiple times and pooling the preservativen free drug [5] In June 2004, hundreds of patients in British Columbia, Canada, were tested for hepatitis after several dialysis machines were found to have leaks, potentially exposing patients to the blood of others who had been dialyzed on that same machine. Finally, in February 2003, a teenager from Mexico died at Duke University after she mistakenly received a kidney transplant from a donor with a different blood type. Many institutions and dialysis facilities have made progress in process redesign to improve patient safety. Another source of error is giving medicine or reprocessed dialyzers to the wrong patient. In March 2004, the Federal Drug Administration issued a rule requiring that certain human drug and biological product labels have bar codes. This bar coding is expected to help reduce the number of medication errors by allowing health care professionals to use bar code scanning equipment. Dialysis facilities can use bar-coded patient identification bracelets or identity cards to confirm correct administration of medications, reused dialyzers and other procedures. 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. Institute of Medicine (IOM, 2000) defined patient safety as the freedom from accidental injury due to medical care or from medical error. It indicated that Patient safety is emphasized the reporting, analysis and prevention of medical error and adverse healthcare events . Since the Institute of Medicine (IOM) reports published, national attention has focusedon improving patient safety through changes in "systems" ofcare. Beginning in 1997, the Joint Commission added new patient safety improvement standards. In further, The National Patient Safety Agency (2003) described patient safety as the process by which an organisation makes patient care safer. This should involve: risk assessment; the identification and management of patient related risk; the reporting and analysis of incidents; and the capacity to learn from and follow up incidents and implement solutions to minimise the risk of them recurring.

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In July 2004, Healthgrades, a leading health care ratings organization, published a study, Patient Safety in American Hospitals ( ). It concluded that there were over one million adverse events associated with Medicare hospitalizations during 2000-2002, resulting in up to 195,000 accidental deaths per year in American hospitals. Then, numerous organizations, government branches, and private companies conduct many research studies to investigate the overall health of patient safety in America and across the globe. Despite the shocking and widely publicized statistics on preventable deaths due to medical errors in Americas hospitals, the report of National Healthcare Quality(2006) had the following sobering assessment: most measures of Quality are improving, but the pace of change remains modest. The rate of improvement accelerated for some measures while a few continued to show deterioration. Variation in heath care quality remains high. In October 2004, World Health Organization (WHO) launched the World Alliance for Patient Safety in response to a World Health Assembly Resolution (2002) - to pay the closest possible attention to the problem of patient safety. Then, all WHO Member States develop patient safety initiatives and policy. The patient safety initiatives include application of lessons learned from business and industry, advancing technologies, education of providers and the public, disclosure of errors, and economic incentives. 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 in the Dialysis Facility There are many possible causes for patient injury within the dialysis environment. The process of providing dialysis treatments includes the use of medications, chemicals, machinery, and physical activity on the part of the patient. When time constraints and staffing difficulties are added to the equation, it is understandable how and why injuries occur. Some common sources of injuries are listed below: Medication errors Blood administration errors Falls Equipment malfunction Chemical exposure Medical Record errors Similar Name errors Deviation from policy & procedure Infection control errors Dialysis prescription errors By examining each of these sources individually, common root causes of errors can be explored and practical solutions developed to prevent future errors and/or patient injury.

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Medication Errors
According to the 1998-2001 National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care product, procedure, and With the advances in the practice of medicine come new drugs to treat disease. Each drug administered in the dialysis facility brings with it the potential for human errors. First, it is important to review the five rights basics of drug administration that nurses are taught early in drug administration training: right patient; right time; right drug; right dosage; and right route. Errors can happen when one or more of the rights are missed. Just knowing and using the five rights cant prevent all errors, but it is a place to begin! To further complicate matters, many medications are packaged similarly. Any drug dosage can be miscalculated or given to the wrong patient. Also added to the picture is the fact that non-licensed staff members are administering routine medications (such as Heparin and Lidocaine) in the dialysis setting. Sometimes agency-based dialysis nurses are utilized to maintain staffing ratios. These temporary staff nurses may not be able to identify patients or be familiar with the facility protocols. Unlike the hospital setting, dialysis patients in the outpatient facility do not wear name band identification bracelets. It is sobering to think about errors that have happened in good dialysis units. Patients have received Hepatitis B vaccine intravenously instead of intramuscularly. Overdoses of Heparin can be easily administered. Serious reactions have occurred from iron administration. Antibiotic administration must be carefully performed as patients may have multiple medication allergies. Careful attention needs to be paid to the packaging and storage of medications. Heparin has been mistaken for Lidocaine and vice-versa- each is a clear solution and may be packaged in similar vials. When possible, avoid purchasing products with similar packaging. However, some corporate purchasing contracts limit the number of available vendors. If look-a-like packaging is unavoidable, try to store products in different locations or draw further attention to the product by using brightly colored alert stickers or another means of alert. The labeling of medication syringes is imperative. The name of the drug, dosage, time, date, and patient name should be clearly indicated. Commercial labels are available to aid staff members in quickly preparing syringes. Ideally, syringes are prepared at the time of use, and administered by the individual that prepared it.

Blood Administration Errors

When administering blood products in a dialysis setting, special considerations must be taken. First, the physicians order must be accurately communicated to the blood bank and patient consent obtained. Follow the facility policies and procedures for proper identification of the patient, administration of blood
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products, and monitoring the patient before, during, and after the receipt of the blood. During dialysis, blood can be given more rapidly than in other settings. It is very easy to miss monitoring the patients vital signs during rapid administration. Care must be taken to monitor the patient adequately during administration. The patient must be aware of the signs and symptoms of a blood reaction following administration. Careful documentation of the entire process is important.

Patient Falls
The average age of dialysis patients is now roughly 65 years of age. Patients frequently have co-morbid conditions that can affect their ability to ambulate. Utilizing patient assist devices such as walkers, canes, or wheel chairs can be of help. Staff member training in the proper techniques of patient transfer is important to prevent injury to either the patient or staff member. The dialysis environment requires the use of water and many other liquid products. Falls can occur when liquids or powders are spilled on the floor identifying wet floors, and having equipment readily available to mop up spills can prevent injury, especially during the change of shift when more people are present in the treatment area. Take the time to evaluate the environment of the dialysis center for hazards that can cause falls and follow up with preventative measures.

Equipment Malfunction
When equipment or maintenance problems cause patient deaths or serious injuries, these should be reported to the manufacturer and/or the Federal Drug Administration (FDA) as appropriate and steps taken to prevent similar occurrences from happening in the future. In dialysis settings, it is important to remember to be able to track the lot numbers of items such as, but not limited to, machine tubing, drugs, and dialyzers. In the event of manufacturing defects, the lot numbers can be used to identify facilities at risk or batches of product that are affected. The Medicare Condition for Coverage 410.2140, states: The physical environment in which ESRD services are furnished affords a functional, sanitary, safe, and comfortable setting for patients, staff and the public. All electrical and other equipment used in the facility is maintained free of defects, which could be a potential hazard to patients and personnel. There is established a planned program of preventive maintenance of equipment used in dialysis and related procedures in the facility.

Chemical Exposure
Any chemical must be treated with respect, as the potential for patient exposure. A variety of chemicals such as dialysate, vinegar, bleach, Renalin, and formaldehyde are used in the dialysis facility. Bleach is used to wipe down surfaces in a facility to prevent the spread of blood borne pathogens posing a risk
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for patient exposure. It is possible to fling bleach onto patients sitting nearby.The packaging of some chemical is similar in nature. Many chemicals are contained in jugs or plastic bottles that can be mistaken for one another. Obtaining and maintaining material safety data sheets (MSDS) on all chemicals is an Occupational Safety and Health Administration (OSHA) requirement. Never use anything from an unlabeled container!

Medical Record Errors

In the dialysis facility, the physical location of the patient chart, Kardex, and treatment flow sheet clipboard may not always be near the patient. In some facilities, only the clipboard with the treatment flow sheet is at the chair side with the patient. Vital information about the patients allergies, co-morbid conditions, medications, dialysis prescription, must be readily available to care givers. Failure to indicate allergies can be catastrophic. Audit your facility treatment flow sheets to determine if vital information is included. Computerized treatment flow sheets are a wonderful by product of advances in dialysis technology. However, it is possible to become overly reliant on the computer-generated documentation. At the Network, we recently reviewed thousands of flow sheets and discovered that even the computerized sheets lack necessary information. The old computer adage of garbage in/ garbage out applies. The machine operator must input the appropriate data for the machine to output a complete record of the treatment. Avoid the pitfall of relying on a false sense of security when using computerized sheets. Handwritten treatment flow sheets are often very difficult to read. Not only do staff members have varying degrees of handwriting skills and the use of unidentifiable abbreviations only increases the possibility of errors. Physicians have traditionally been ridiculed for illegible handwriting. After the Network review of handwritten flow sheets, it is safe to say that all staff members have the potential for messy writing.

Deviation from Facility Policy & Procedure

When a staff member operates outside of the protection of facility policies and procedures, the patient, staff member, facility, and possibly corporation are put at great liability risks. The importance of following policies and procedures cannot be over emphasized. As stated in the Medicare Conditions for Coverage 405.2136: The ESRD facility has written policies, approved by the governing body, concerning the provision of dialysis and other ESRD services to patients. The governing body reviews implementation of policies periodically to ensure that the intent of the policies is carried out. These policies are developed by the hysician responsible for supervising and directing the provision of ESRD services, or the facilitys organized medical staff (if there is one), with the advice of (and with provision for review of such policies from time to time, but at least annually, by) a group of professional personnel associated with the facility, including, but not limited to, one or more physicians and one or more registered nurses

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experienced in rendering ESRD care. The physician-director of the facility is designated in writing to be responsible for the execution of patient care policies. If the responsibility for day-to-day execution of patient care policies has been delegated by a physician director to (or, in the case of a self-dialysis unit, to another licensed health practitioner) a registered nurse, the physician-director provides medical guidance in such matters.

Infection Control Errors

Even with the availability of Hepatitis B vaccine, it is still important to protect the dialysis patient from blood borne pathogens and other sources of infection in the dialysis facility. Following the facility policy for disinfecting surfaces, administration of vaccine, and laboratory surveillance remains a high priority. Acquired immune deficiency (AIDS), Tuberculosis, Hepatitis B, Vancomycin Resistant Enterococcus (VRE), and Methicillin Resistant Staphylococcus auras (MRSA) are just a few examples of pathogens potentially present in a dialysis facility. Additionally, getting back to the basics of good hand washing techniques cannot be stressed enough.

Dialysis Prescription Errors

The dialysis prescription is an individualized method for administering the most beneficial dialysis treatment to the patient. Components of the dialysis prescription include treatment duration, model and size of dialyzer, blood flow rate, and dialysis flow rate. Deviation from the prescription can result in injury to the patient or inadequate treatments. During a recent flow sheet audit, the Network staff reviewed over 2,000 flow sheets comparing them to the dialysis prescription. Of the 2685 flow sheets reviewed, 93.9% of the patients achieved the correct duration of treatment, 95.9% documented that the patients received the correct dialyzer, and 91.4% of the patients achieved the correct blood flow rate. While these numbers are good there is more room for improvement. Inadequate documentation was noted on both computerized and handwritten sheets. Provide your Medicare beneficiaries with the dialysis prescription written by the physician for which you are being reimbursed by CMS.

Adequate Staffing in the Dialysis Facility

It is not the intention of this article to define adequate staffing ratios, but facilities providing dialysis service to Medicare beneficiaries must staff according to the needs of the patients. By evaluating your own unique dialysis patient population, staff training, and patient needs, your patient care team can determine the properly trained personnel are present in adequate numbers to meet the needs of the patients, including those arising from medical and non-medical emergencies. (a) Standard: Registered Nurse, The dialysis facility employs at least one full time qualified nurse responsible for nursing services. (b) Standard; On-duty personnel, whenever patients are undergoing dialysis: (1) One currently licensed health professional (e.g., physician, registered nurse, or licensed practical nurse) experienced in rendering ESRD care is on duty to oversee ESRD patient care; (2) An adequate number of personnel are present so that the patient/staff ratio is
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appropriate to the level of dialysis care being given and meets the needs of patients; and (3) An adequate number of personnel are readily available to meet medical and non-medical needs.

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Chapter 6: Conclusion
It is the responsibility of all health care providers to work together to promote a safe environment for patients in the dialysis care setting. Any error that causes harm to a patient is on error too many. Said Dr. Nancy Dickey, past president of the American Medical Association Would you be comfortable allowing your favorite family member or a good friend to receive his or her dialysis treatments at your facility? If not, work creatively with your care team to improve systems at your dialysis center. Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing. said William Richardson, President of the W. K. Kellogg Foundation. What proactive steps can your facility take to make dialysis treatments safer for your patients? A national program, 5 Steps to Safer Health Care, urges patients to:

Speak up if you have questions or concerns. Keep a list of all your medications. Make sure you get the results of any test or procedures. Talk with your doctor and health care team about your options. Make sure you understand what will happen if you need surgery.

We should ask our doctor and healthcare team about safety efforts in your dialysis unit. Is there a culture of safety where patients and staff are encouraged to report mistakes, adverse events and near-misses in a non-punitive atmosphere, where fingers of blame will not be pointed but action will be taken to improve systems of care? Is there a program to reduce falls and to regularly review medications and avoid bad drug interactions? If dialyzers are reused, what systems are in place to prevent wrong patient assignments to dialyzers? Have processes of care been reviewed to simplify and standardize? Are checklists used? Are you doing your part to ensure your safety?

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References
Kliger AS, Diamond LH. Patient Safety in End-Stage Renal Disease: How Do We Create a Safe Environment? Advances in Renal Replacement Therapy, Vol 8, No 2 (April), 2001: pp 131-137. Diamond LH. Patient safety: the challenges and opportunities for the ESRD program. Adv Ren Replace Ther 2000 Oct; 7(4 suppl 1):S100-4. Kohn LT, Corrigan J, Donaldson MS et al: Committee on Quality of Health Care in America. To err is human: Building a safer health system. Washington, DC, National Academy Press 1999. Medicare Conditions for Coverage 2001 Hemodialysis Adequacy Quality Improvement Project, ESRD Network #12, flow sheet audit preliminary data. Four Simple Steps to Reduce Errors. Drug Topics, Medical Economics Co. April 6, 1997. Medical Errors Preventable. Neergaard L. Associated Press 2000. Pepper GA. Errors in drug administration by nurses. From Understanding and Preventing Drug Misadventures Conference.

Singer D, Collaborative Leadership For and ESRD Patient Safety Initiative is Formed. Contemporary Dialysis & Nephrology April 2001: pp 36-38. This was supported under CMS contract HHSM-500-20 CHAPTER 5. RESULTS CHAPTER 6. ANALYSIS CHAPTER 7. DISCUSSION CHAPTER 8. RECOMMENDATIONS CHAPTER 9. CONCLUSION

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