title: Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective.
abstract: BACKGROUND
  There has been resurgent interest in home hemodialysis (HD) in recent years because of the reported benefits and its excellent safety record. However, the potential for adverse events, including potentially catastrophic ones, exists when patients are performing HD in their homes without supervision. There is a lack of literature on this important topic.
  
  
  METHODS
  Quality improvement report.
  
  
  METHODS
  We present the experience of 2 adult home HD programs in Canada from 2001 to 2012, including a total of 190 patients and approximately 500 patient-years of treatments.
  
  
  METHODS
  We retrospectively reviewed all life-threatening adverse events occurring in our programs and re-examined our approach to patient training, retraining, and safety monitoring.
  
  
  RESULTS
  We report 1 death and 6 potentially fatal adverse events, yielding a crude rate of 0.060 events/1,000 dialysis treatments. Six of 7 events involved significant blood loss (including 1 exsanguination); 5 of 7 events involved human error with lapses in protocol adherence. Because such events are rare, evaluation of specific intervention strategies will require much longer follow-up.
  
  
  CONCLUSIONS
  Retrospective identification of cases. A specific quality improvement initiative was not undertaken.
  
  
  CONCLUSIONS
  Life-threatening adverse events in home HD are uncommon; however, when one does occur, this should prompt review of home HD-related policies and procedures to make this therapy even safer.
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta.
authors.forename: Ben
authors.initials: B
authors.lastname: Wong
authors.affiliation: Division of Nephrology, University of Ottawa, Ottawa, Ontario.
authors.forename: Deborah
authors.initials: D
authors.lastname: Zimmerman
authors.affiliation: Northern Alberta Renal Program, Alberta Health Services, Alberta, Canada.
authors.forename: Frances
authors.initials: F
authors.lastname: Reintjes
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta.
authors.forename: Mark
authors.initials: M
authors.lastname: Courtney
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta.
authors.forename: Scott
authors.initials: S
authors.lastname: Klarenbach
authors.affiliation: Office of the Chief Medical Examiner, Province of Alberta; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Graeme
authors.initials: G
authors.lastname: Dowling
authors.affiliation: Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta. Electronic address: robert.pauly@ualberta.ca.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Pauly
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006437:Hemodialysis, Home / Q000009:adverse effects* / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011785:Quality Assurance, Health Care / Q000592:standards*; D058996:Quality Improvement / Q000592:standards*; D012189:Retrospective Studies; D012648:Self Care / Q000009:adverse effects* / Q000379:methods / Q000592:standards*
keywords: Adverse event; air embolism; exsanguination; hemorrhage; home hemodialysis; nocturnal hemodialysis