Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
01 Apr 2022
01 Apr 2022
Historique:
pubmed:
28
9
2021
medline:
3
5
2022
entrez:
27
9
2021
Statut:
ppublish
Résumé
Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy. From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff. Of the 281 bleeding events reviewed, 188 (67%) were unwitnessed and 54 (19%) were associated with an alteration in mental status. Most deaths (n = 11; 79%) were associated with central venous catheter access. Root cause analyses reported 83 root causes, of which 33% identified physical barriers to direct observation or an equipment issue.Action plans addressed policy/procedures (30%), training/education (20%), and changes to environment/equipment (19%). Patient Safety Advisory publication was associated with a significant increase in low-harm PS reports, from 9 to 18 per year (P = 0.001). Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting.
Identifiants
pubmed: 34569993
doi: 10.1097/PTS.0000000000000898
pii: 01209203-202204000-00018
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e620-e625Informations de copyright
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors disclose no conflict of interest.
Références
Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2019. 2019. Available at: https://www.cdc.gov/kidneydisease/publications-resources/2019-national-facts.html . Accessed November 27, 2020.
Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2019 Annual Data Report: epidemiology of kidney disease in the United States. Am J Kidney Dis . 2020;75(1 Suppl 1):A6–A7.
Department of Veterans Affairs and Veterans Health Administration. Veterans Health Administration Directive 1053, Chronic Kidney Disease Prevention, Early Recognition, and Management. 2020. Available at: https://www.va.gov/vhapublications/publications.cfm?pub=1 . Accessed December 2, 2020.
Department of Veterans Affairs, Veterans Health Administration. VHA National Kidney Program Internal Data & Reporting Portal. Average number of treatments per week. 2020. Available at: https://secure.vssc.med.va.gov/Dialysis/default.aspx . Accessed November 27, 2020.
Axley B, Speranza-Reid J, Williams H. Venous needle dislodgement in patients on hemodialysis. Nephrol Nurs J . 2012;39:435–445; quiz 446.
Gill JR, Storck K, Kelly S. Fatal exsanguination from hemodialysis vascular access sites. Forensic Sci Med Pathol . 2012;8:259–262.
Ellingson KD, Palekar RS, Lucero CA, et al. Vascular access hemorrhages contribute to deaths among hemodialysis patients. Kidney Int . 2012;82:686–692.
Jose MD, Marshall MR, Read G, et al. Fatal dialysis vascular access hemorrhage. Am J Kidney Dis . 2017;70:570–575.
Department of Veterans Affairs National Center for Patient Safety. Patient Safety Advisory ADO9-02: bleeding episodes during dialysis. Published October 21, 2008. Available at: https://www.patientsafety.va.gov/docs/alerts/BleedingEpisodesDuringDialysisAD09-02.pdf . Accessed December 2, 2020.
Department of Veterans Affairs, Veterans Health Administration Handbook 1050.01, VHA National Patient Safety Improvement Handbook. Published March 4, 2011. Available at: https://www.patientsafety.va.gov/professionals/publications/handbook.asp . Accessed November 27, 2020.
Mills PD, Soncrant C, Gunnar W. Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units. BMJ Qual Saf . 2021;30:567–576. doi:10.1136/bmjqs-2020-011312.
doi: 10.1136/bmjqs-2020-011312
Military Health System. Joint Patient Safety Reporting. 2020. Available at: https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Patient-Safety/Joint-Patient-Safety-Reporting . Accessed December 2, 2020.
Communication with the VHA National Kidney Program Office on September 17, 2020.
Matos JF, Pinto B, Félix C, et al. Needle Dislodgement Management in Dialysis—Causes and Consequences . Genoa, Italy: Paper presented at: 47th EDTNA/ERCA International Conference; 2018: Available at: https://www.edtnaerca.org/resource/edtna/files/2018-genoa-posters/E-P%20019.pdf . Accessed November 27, 2020.
Watts BV, Rachlin JR, Gunnar W, et al. Wrong site spine surgery in the Veterans Administration. Clin Spine Surg . 2019;32:454–457.
Gunnar W, Soncrant C, Lynn MM, et al. The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration. J Patient Saf . 2020;16:255–258.
Zeigler SA. Prevent dangerous hemodialysis catheter disconnections. Nursing . 2007;37:70.
Van Waeleghem JP, Chamney M, Lindley EJ, et al. Venous needle dislodgement: how to minimise the risks. J Ren Care . 2008;34:163–168.
VA National Center for Patient Safety. Patient Safety Alert AL10-05: Fresenius HemaClip used during dialysis. 2010. Available at: https://www.patientsafety.va.gov/docs/alerts/AL10-05WWW.pdf . Accessed December 2, 2020.
Centers for Medicare & Medicaid Services. Quality, Safety & Oversight—Guidance to Laws & Regulations: Dialysis. End Stage Renal Disease (ESRD) Program Interpretive Guidance. 2008. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Dialysis . Accessed December 2, 2020.
Thomas A, Silver SA, Rathe A, et al. Feasibility of a hemodialysis safety checklist for nurses and patients: a quality improvement study. Clin Kidney J . 2016;9:335–342.
Chen CK, Tsai YC, Hsu HJ, et al. Depression and suicide risk in hemodialysis patients with chronic renal failure. Psychosomatics . 2010;51:528–528.e6.
Dreifuss RM, Silberzweig JE. Inadvertent central venous catheter removal: a fatal complication. J Vasc Interv Radiol . 2008;19:1691–1692.
Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis . 2020;75(4 Suppl 2):S1–S164.
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes [published online October 8, 2020]. J Patient Saf . doi:10.1097/PTS.0000000000000768.
doi: 10.1097/PTS.0000000000000768
VA National Center for Patient Safety. Action Hierarchy. 2017. Available at: https://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf . Accessed December 2, 2020.
Macrae C. The problem with incident reporting. BMJ Qual Saf . 2016;25:71–75.