title: A descriptive report of errors and adverse events in chronic hemodialysis units.
abstract: With the combination of technical equipment, medication administration, and caregiver-delivered treatment, opportunities for adverse events and medical errors exist in hemodialysis units. There are no studies describing the type and frequency of medical errors and adverse events in hemodialysis units. This study examines standard adverse events and medical errors reported on routine quality assurance forms by the clinical directors of four hemodialysis units between January 2004 and June 2005. The units varied in size (45 -108 patients), average number of hemodialysis treatments provided (524 -1,333/month), and staffing ratios (1:3 - 1:9.5). In total, 88 errors occurred in 64,541 dialysis treatments (1 event every 733 treatments). Infiltration of the hemodialysis access (n = 31 ) and clotting of the dialysis circuit (n = 19) were also fairly common while dialysis equipment problems occurred relatively rarely (30 occurrences in 64,541 treatments, or 1 event every 2,151 treatments). Thirty-five medication errors occurred (1 every 2,15 1 treatments); omission of an ordered medication was the most common (24/35, 69%). Nine patients fell and six of the falls occurred after a dialysis treatment. No patients required hospitalization as a result of the adverse events or errors. Errors and events were more common in the larger units but did not seem to be directly related to unit staffing ratios. Adverse events in hemodialysis units are fairly common and should be included among routine quality improvement issues addressed by dialysis providers and caregivers. More study of this issue is needed.
authors.forename: Jean L
authors.initials: JL
authors.lastname: Holley
mesh_terms: D004282:Documentation; D004868:Equipment Failure / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand; D006436:Hemodialysis Units, Hospital / Q000458:organization & administration; D006742:Hospital Bed Capacity / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008485:Medical Audit; D019300:Medical Errors / Q000379:methods / Q000451:nursing / Q000706:statistics & numerical data*; D009741:Nursing Staff, Hospital / Q000458:organization & administration; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration; D011785:Quality Assurance, Health Care; D006435:Renal Dialysis / Q000009:adverse effects* / Q000295:instrumentation / Q000451:nursing; D012308:Risk Management; D013597:Systems Analysis; D017749:Total Quality Management; D014768:Virginia