Is your dialysis unit safe?Are there opportunities to improve

safety?

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

Institute of Medicine Report (1999)

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

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

February 18, 2003

This was actually the second girl in several This was actually the second girl in several months to die after receiving a transplant months to die after receiving a transplant with the wrong blood typewith the wrong blood type

Dallas, 2002: A patient received a partial Dallas, 2002: A patient received a partial liver transplant from her father (type A) - liver transplant from her father (type A) - but it was her mother who had compatible but it was her mother who had compatible (type O) blood.(type O) blood.

Laboratory mix-up was not detected until Laboratory mix-up was not detected until 19 days post-op 19 days post-op

““There’s more double-checking and There’s more double-checking and systematic avoidance of mistakes at systematic avoidance of mistakes at Starbucks than at most health-care Starbucks than at most health-care institutions.”institutions.”

- Carolyn M. Clancy, Director AHRQ- Carolyn M. Clancy, Director AHRQ

““It is fundamental that the It is fundamental that the hospital shall do nothing to harm hospital shall do nothing to harm the patient … my view you know the patient … my view you know is that the ultimate destination of is that the ultimate destination of all nursing is the nursing of the all nursing is the nursing of the sick in their own homes … I look sick in their own homes … I look to the abolition of all hospitals to the abolition of all hospitals and workhouse infirmaries. But and workhouse infirmaries. But it is no use to talk about the it is no use to talk about the year 2002.”year 2002.”

Florence Nightingale Florence Nightingale Letter to Henry Bonham Letter to Henry Bonham Carter circa 1867Carter circa 1867

U.S. Has Most Medical Errors

34% of US patients said they were given a wrong 34% of US patients said they were given a wrong medication or dose, experienced a medical mistake in medication or dose, experienced a medical mistake in treatment, received incorrect test results, or had a delay treatment, received incorrect test results, or had a delay in being notified of abnormal test results in the past 2 in being notified of abnormal test results in the past 2 years.years.

1/3 US patients had a physician visit in which their test 1/3 US patients had a physician visit in which their test results or medical records were unavailable, or a results or medical records were unavailable, or a

physician ordered a test that had already been done.physician ordered a test that had already been done.

Schoen et. al., Health Affairs Nov 3, 2005

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

The “Blame Trap”

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

-- Reason, 1994

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

Dialysis Chains: Top Patient Safety Issues

• Patient Falls

• Medication Errors

• Access-Related Events

• Dialyzer Errors

• Excess blood loss and prolonged bleeding

Risk of Hip Fracture Among Dialysis and Renal Transplant Patients

• 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.

December 18, 2002

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); 163:2014-2018

Medication Errors: Major Safety Issue in Hospitals

Health & Safety Survey Project: Patients & Professionals

Funding by Abbott Laboratories & CMS Special Project

Partners

Sponsors

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

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

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

Percent Professional Respondents by Role Group

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Assistants Nurses Managers DocsRole Groups

Per

cen

t R

esp

on

den

ts

Percent ESRD Patients & Survey Respondents by Network

Figure 1: Percent ESRD Patients and Survey Respondents by Network

3%

7%

4%4%

9%

6% 6%

4%

6%

4% 4%

9%

3%

5%

8%

4%

5%

10%

6%

7%7%

4%

6%

7%

5%

6%

4%

7%

5%

4% 4%3%

8%

6%

5%5%

0%

2%

4%

6%

8%

10%

12%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18Network

Pe

rce

nt

All ESRD Patients

Survey Sample

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%

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

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.”

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

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

Handwashing: Staff View

Professional Survey: Past 3 months:

• 27% professionals reported observing staff fail to wash hands or change gloves before touching a patient’s access

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

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

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

Percent Professionals Indicating Each Reason for Medical Mistakes

0%

10%

20%

30%

40%

50%

60%

Staff do not follow procedures

Not enough staff to handle workload

Staff not disciplined when don't follow procedures

Staff not comfortable reporting m

edical errors

Equipment breaks down

Staff work too many hours

Patients are difficult to work with

Staff not given needed training

No continuous quality improvem

ent program

Do not have needed supplies

Other, please specify:

Reasons for Medical Mistakes

Per

cen

t P

rofe

ssio

nal

Res

po

nd

ents

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

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

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