title: Hidden hemolysis.
abstract: The exact cause of this case of hemolysis has not been definitively determined, although evidence has pointed to a possible defect in the dialysis blood lines, which remains the only plausible etiology. However, we must always keep patient safety at the forefront so that the cause can be identified. The majority of our dialysis nursing staff has had extensive hemodialysis experience with the current equipment. None of us had ever experienced hemolysis before. When the etiology remained elusive, we kept struggling with the thought of "Why after all these years?" We must never lose sight of the fact that day in and day out we perform thousands of technologically complex procedures that have many potential complications. Since this incident, we have heard of other similar cases past and present. We reached out to a company that assists with medical investigations to determine if this was being experienced in other facilities. Since then, other facilities have contacted us with very similar stories. Why are we seeing more of this now? Do higher hemoglobins in our patients play a role in this? Are proper quality controls followed by manufacturers? There are many questions that need to be answered and research to be done. Lastly, as medical professionals, we must network and share the information we have been able to gather. This is about patient safety, not blame.
authors.forename: Paula
authors.initials: P
authors.lastname: Dutka
mesh_terms: D000368:Aged; D019963:Clinical Chemistry Tests; D005260:Female; D006461:Hemolysis; D006801:Humans; D010808:Physical Examination; D006435:Renal Dialysis / Q000009:adverse effects*