Is your dialysis unit safe Are there opportunities to improve safety

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Is your dialysis unit safe?Are there
opportunities to improve safety?
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We are all humanWe make mistakes

• Mistakes are common.
• They occur daily.
• Mistakes are part of our every day lives.
• When you are admitted to a hospital (or dialysis
  unit) you expect
• NO MISTAKES

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Institute of Medicine Report (1999)

• 44,000 98,000 people die each year from medical
  errors that occur in hospitals. That's more than
  die from motor vehicle accidents, breast cancer
  and AIDS--combined--making medical errors the
  fifth leading cause of death in this country.

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February 18, 2003

• DURHAM, North Carolina (AP) -- A teenager from
  Mexico who mistakenly received organs from a
  donor with a different blood type was not
  expected to live more than a few days, a family
  friend said Tuesday.

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• This was actually the second girl in several
  months to die after receiving a transplant with
  the wrong blood type
• Dallas, 2002 A patient received a partial liver
  transplant from her father (type A) - but it was
  her mother who had compatible (type O) blood.
• Laboratory mix-up was not detected until 19 days
  post-op

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• Theres more double-checking and systematic
  avoidance of mistakes at Starbucks than at most
  health-care institutions.
• - Carolyn M. Clancy, Director AHRQ

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It is fundamental that the hospital shall do
nothing to harm the patient my view you know is
that the ultimate destination of all nursing is
the nursing of the sick in their own homes I
look to the abolition of all hospitals and
workhouse infirmaries. But it is no use to talk
about the year 2002.
Florence Nightingale
Letter to Henry Bonham
Carter circa 1867
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U.S. Has Most Medical Errors
Schoen et. al., Health Affairs Nov 3, 2005

• 34 of US patients said they were given a wrong
  medication or dose, experienced a medical mistake
  in treatment, received incorrect test results, or
  had a delay in being notified of abnormal test
  results in the past 2 years.
• 1/3 US patients had a physician visit in which
  their test results or medical records were
  unavailable, or a physician ordered a test that
  had already been done.

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Safety Conundrum

• Medical workers are expected to function without
  error.
• Errors are made by highly competent, careful and
  conscientious people for the simple reason that
  everyone makes mistakes every day.

Lucian Leape, 1997
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The Blame Trap

• Blame is universal, natural, emotionally
  satisfying, and legally convenient, it does
  nothing to make healthcare safer.
• -- Reason, 1994

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Systems can be designed...

• To help prevent errors
• To make them detectable so that they can be
  intercepted
• To mitigate them if they are not intercepted

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Dialysis Chains Top Patient
Safety Issues

• Patient Falls
• Medication Errors
• Access-Related Events
• Dialyzer Errors
• Excess blood loss and prolonged bleeding

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Risk of Hip Fracture Among Dialysis and Renal
Transplant Patients
December 18, 2002

• Incidence of hip fracture in dialysis patients
  2.9/1,000 patients/year
• Extrapolation to national incidence 800 hip
  fractures each year in dialysis patients.

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Medication Errors Major Safety Issue in Hospitals

• Pharmacists on Rounding Teams Reduce Preventable
  Adverse Drug Events in Hospital General Medicine
  Units
• Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA
• Arch Intern Med. 2003 (Sept) 1632014-2018

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Health Safety Survey Project Patients
Professionals
Sponsors
Partners
Funding by Abbott Laboratories CMS Special
Project
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Patient Survey

• Invitations to participate in an anonymous survey
  sent to 3,587 patients drawn from a
  representative national patient sample
• Network 1 implemented the patient selection and
  coordinated survey mailing and responses
• Surveys completed by 1,762 patients

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Patient Survey

• Sample Characteristics
• Mean Age 64 yrs.
• Gender 54 males
• Race 67 Caucasian, 28 African Amer.
• Dialysis Type all in-center hemodialysis
• Vascular access 21 catheter

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Professional Survey

• Invitations to participate in an anonymous
  web-based survey widely distributed by RPA,
  Networks, Professional Meetings
• Web-based Surveys completed by 649 professionals

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Percent ESRD Patients Survey Respondents by
Network
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Patient Falls Patients View

• Patient Survey last 3 months
• 95 patients had never fallen at the dialysis
  unit
• 5 fell extrapolated nationwide 15,240 falls
• 55 patients (3.1) reported falls in the unit
• Some had several falls mean falls 1.3
• Reason for falls
• Feeling dizzy or weak 60

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Patient Falls Staff View

• Professional Survey Past 3 months
• Mean falls 0.65
• If presume 100 pts/nurse/yr,
  falls rate 26/1,000 pts/yr
• 2002 Hip fractures 2.9/1,000 pts/yr
• Reasons for falls
• Feeling dizzy or weak 40

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Needle Insertion

• Patient Survey Past 3 months
• 46 patients report staff sometimes, usually or
  always has problems inserting needles
• 6 say the last time there were problems, staff
  tried to insert the needle more than 3 times
  before getting help
• Additional 24 say staff tried 3 times before
  getting help

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Medication Safety Patients View

• Patient Survey Past 3 months
• Physician review of medications with patients
• 40 patients report that they discuss their meds
  with their doctor only sometimes.

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Medication Safety Staff View

• Professional Survey Past 3 months
• 43 professionals report 1 or more instances of
  patient given the wrong medicine or medicine at
  wrong time
• 63 report patients fail to receive 1 of their
  meds at times
• 37 report that a patient is given wrong dose of
  a medication at least once
• Overall 77 staff indicate a patient had a
  medication omission or error in past 3 months

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Handwashing Patients View

• Patient Survey Past 3 months
• 11 of patients report seeing nurses or
  technicians who do not washing their hands or
  change gloves before touching their access site

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Handwashing Staff View

• Professional Survey Past 3 months
• 27 professionals reported observing staff fail
  to wash hands or change gloves before touching a
  patients access

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Set-up Predialysis Patients View

• Wrong Dialyzer Set-ups
• 17 patients reported problems with settings on
  their dialysis machine
• 3 wrong dialyzer set up for treatment
• 2 wrong dialyzing solution set up
• 3 patients report a treatment when weight not
  recorded
• 6 patients report a treatment when BP not
  obtained prior to treatment
• 86 Staff report a patient blood sample was not
  taken when ordered in past 3 months

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Overall Assessment of Safety

• Patients
• 27 patients have seen at least 1 medical mistake
  in past 3 months
• 16 patients say they sometimes feel unsafe at
  the dialysis center
• 49 patients sometimes, usually or always worry
  that someone will make a mistake

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Overall Assessment of Safety

• Professionals
• 30 professionals said mistakes occur more than
  rarely
• 30 professionals said the last observed mistake
  was not trivial
• Medical mistakes are connected to failure to
  adhere to procedures (59 of staff reporting
  medical mistakes)
• Most believe their dialysis facility has a
  positive patient safety environment

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Conclusions

• Patients worry about medical mistakes more than
  they experience them (49)
• Most staff (87) are aware that medical mistakes
  have occurred in past 3 months

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Conclusions

• Medication errors recognized frequently by
  patients and staff
• Patient Falls remain frequent source of adverse
  events
• Handwashing is recognized as patient safety issue
  in dialysis units
• Correct dialysis set-up and predialysis
  procedures are safety issues
• Adherence to procedures is a major source of
  medical mistakes

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What Can You Do?

• Wash your hands
• Review medications with your patients frequently
• Assess patients for risk factors for falls
• CMS new Conditions of Coverage require a Quality
  Assessment Performance Improvement Program
  participate
• Help design a culture of safety in your unit