Wilkinson WE, Cauble LA, Patel VL. J Patient Saf. 2011;7:213-223.
This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.
Barletta JF, Barletta GM, Brophy PD, Maxvold NJ, Hackbarth RM, Bunchman TE. Pediatr Nephrol. 2006;21:842-845.
The authors identified errors associated with continuous renal replacement therapy and found that use of industry-prepared, rather than manually compounded, solutions minimized errors.
Kliger AS. Blood Purif. 2006;24:19-21.
The author offers a 5-point plan to help recognize and prevent errors in dialysis facilities.
The investigators analyzed electronic records and found that dosing errors were common in ambulatory care settings for patients with renal insufficiency. They conclude that computerized decision support systems should be implemented in ambulatory care.
Treatments delivered in the home carry the potential for certain risks. This commentary examines the literature on dialysis-related incidents occurring in the home setting and presents a framework to help address avoidable adverse events in home hemodialysis.
Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awareness of safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure, and describes techniques for clinicians to reduce risk of errors.
Kliger AS. Clin J Am Soc Nephrol. 2015;10:688-695.
Failure to consider human factors and poor communication can contribute to dialysis treatment errors. This commentary discusses safety concerns in dialysis facilities, including medication errors, patient falls, and health care–associated infections. The authors recommend human factors engineering, patient engagement, and simulation as promising strategies to enhance safety in this setting.
Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476.
This study utilized AHRQ patient safety culture surveys to assess nephrology nursing practices across the country. The survey revealed an overall interest in patient safety and teamwork, but also identified numerous areas for improvements, including handoffs, infection control, and medication errors.
This commentary relates how bullying and other disruptive behaviors remain a pervasive issue in health care. The authors describe its impact on safety culture and highlight six standards to help address behaviors that hinder communication and transparency.
Reilly JB, Marcotte LM, Berns JS, Shea JA. Jt Comm J Qual Patient Saf. 2013;39:70-76.
In this study, communication between inpatient and outpatient dialysis units at discharge was highly variable.
An elderly man presented to an emergency department (ED) with new onset chest pain. In reviewing the patient's electronic medical record (EMR), the ED physician noted a history of "PE," but the patient denied ever having a pulmonary embolus. Further investigation in the EMR revealed that, many years earlier, the abbreviation was intended to stand for "physical examination." Someone had mistakenly copied and pasted PE under past medical history, and the error was carried forward for years.
A woman with end-stage renal disease, who often skipped dialysis sessions, was admitted to the hospital with fever and given intravenous opiates for pain. Because her permanent arteriovenous graft was clotted, she had been receiving dialysis via a temporary femoral catheter, increasing her risk for infection. Blood cultures grew yeast; the patient was diagnosed with fungal endocarditis, likely caused by injections of opiates through her catheter.