Patient Safety Events


Hand HygieneHand Hygiene


Accumulation and transmission of germs on hands are transmitted by touching one's self, patients and surfaces in the patient environment. Infections are a serious problem in healthcare facilities and many infections are transmitted on the hands of healthcare personnel. Hand hygiene practices - the use of alcohol-based hand rubs or use of soap and water before and after patient contact, removal of gloves and contact with the immediate patient care environment - protect both healthcare personnel and patients from contact with infectious agents. Failure to practice hand hygiene may be caused by lack of equipment; low staffing ratios; allergies to hand washing products; insufficient knowledge about risks posed by not practicing hand hygiene; time required; or casual attitude by staff towards hand hygiene. Proper hand hygiene breaks the chain of infection transmission and minimizes micro organisms acquired by contact with infected surfaces.



Patient FallsPatient Falls


Patient falls are defined as any untoward event in which the patient comes to rest unintentionally on the floor. Falls are largely preventable occurrences that injure patients, cause hospitalizations, and significantly increase healthcare costs. Most ESRD patients who fall indicate they fall following dialysis treatment, and they fall because they feel dizzy or weak. Additional attention to post-dialysis blood pressure levels, assistance as patients initially stand up coupled with queries about their steadiness, and removal of physical obstacles to patient navigation could all serve to reduce patient falls.



Incorrect DialyzerIncorrect Dialyzer or Dialyzing Solution


The wrong dialyzer or dialyzing solution being set-up for a patient is a dangerous event that can result in great harm to patients. Feasible remedies for ensuring that initial set-up errors do not result in patient harm range from patient and professional education to procedural safeguards such as technician checklists and rules for set-up procedures. Increasing patient involvement in their dialysis care and safety issues may provide another approach to safeguarding against dialyzer solution errors.



Medication OmissionsMedication Omissions or Errors


Medication errors include giving a patient the wrong medication, giving medication at the wrong time, being given the wrong dose of a medication, or a patient failing to receive one of his/her medications. The consequence of each occurrence of a medication error, particularly omitting a patient's medication, can be quite significant and result in medical harm particularly when one considers that dialysis patients take large numbers of different medications each day; most take between 6 and 10 medications per day (based on the patient survey). Patients ascribe medication problems to inadequate communication. Medication omission and errors might be resolved through a combination of professional and patient education and systems changes that build safeguards into medication routines and procedures.



Non Adherence to ProceduresNon Adherence to Procedures


Failure to adhere to procedures, including the performance of routine completion of pre- and post-dialysis tasks such as taking patients' weight and blood pressure, leads to medical errors, increased risk of hospitalization and mortality. Non-adherence may also include failing to follow procedures regarding trouble with needle insertion and failure to complete event reports when medical errors occur. Non-adherence may also include patients' skipping or shortening dialysis treatments thereby increasing their odds of mortality. Non-adherence problems may reflect issues with procedural guidance, training, and/or enforcement.



Venous Needle DislodgmentVenous Needle Dislodgement


Venous Needle Dislodgement (VND) is a consequence of hemodialysis that occurs when the needle delivering the cleansed blood from the machine back into the patient either partially or completely comes out of the access site. The consequences of VND range from minor blood loss to exsanguination. Patients at increased risk for VND include those that are restless or agitated or those who are mentally or cognitively challenged, such as those with dementia. Strategies for preventing VND include keeping access sites uncovered, anchoring lines to the patient rather than the bed or chair, and using a consistent taping technique with all patients.