Maintaining safety in the dialysis facility.
Errors in dialysis care can cause harm and death. While dialysis machines are rarely a major cause of morbidity, human factors at the machine interface and suboptimal communication among caregivers are common sources of error. Major causes of potentially reversible adverse outcomes include medication errors, infections, hyperkalemia, access-related errors, and patient falls. Root cause analysis of adverse events and "near misses" can illuminate care processes and show system changes to improve safety. Human factors engineering and simulation exercises have strong potential to define common clinical team purpose, and improve processes of care. Patient observations and their participation in error reduction increase the effectiveness of patient safety efforts.
Yale University School of Medicine, Yale New Haven Health System, New Haven, Connecticut Alan.Kliger@ynhh.org.
Alan S
AS
Kliger
D004867:Equipment Design; D004868:Equipment Failure; D006268:Health Facilities / Q000592:standards; D006801:Humans; D019300:Medical Errors / Q000401:mortality / Q000517:prevention & control*; D008508:Medication Errors; D000067491:Near Miss, Healthcare; D061214:Patient Safety; D017064:Process Assessment, Health Care / Q000592:standards; D065840:Protective Factors; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D006435:Renal Dialysis / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality / Q000592:standards; D018570:Risk Assessment; D012307:Risk Factors; D017751:Safety Management / Q000592:standards; D016896:Treatment Outcome
dialysis; medication errors; patient safety