Premium
Dialysis Facility Safety: Processes and Opportunities
Author(s) -
Garrick Renee,
Morey Rishikesh
Publication year - 2015
Publication title -
seminars in dialysis
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.899
H-Index - 78
eISSN - 1525-139X
pISSN - 0894-0959
DOI - 10.1111/sdi.12395
Subject(s) - medicine , patient safety , harm , medical emergency , human error , dialysis , near miss , root cause analysis , risk analysis (engineering) , intensive care medicine , health care , forensic engineering , surgery , engineering , political science , law , economics , economic growth
Unintentional human errors are the source of most safety breaches in complex, high‐risk environments. The environment of dialysis care is extremely complex. Dialysis patients have unique and changing physiology, and the processes required for their routine care involve numerous open‐ended interfaces between providers and an assortment of technologically advanced equipment. Communication errors, both within the dialysis facility and during care transitions, and lapses in compliance with policies and procedures are frequent areas of safety risk. Some events, such as air emboli and needle dislodgments occur infrequently, but are serious risks. Other adverse events include medication errors, patient falls, catheter and access‐related infections, access infiltrations and prolonged bleeding. A robust safety system should evaluate how multiple, sequential errors might align to cause harm. Systems of care can be improved by sharing the results of root cause analyses, and “good catches.” Failure mode effects and analyses can be used to proactively identify and mitigate areas of highest risk, and methods drawn from cognitive psychology, simulation training, and human factor engineering can be used to advance facility safety.