1. Is your dialysis unit safe? Are there opportunities to improve safety?

2. We are all human We make mistakes Mistakes are common. They occur daily. Mistakes are part of our every day lives. When you are admitted to a hospital (or dialysis unit) you expect NO MISTAKES

5. Institute of Medicine Report (1999) 44,000 – 98,000 people die each year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer and AIDS-- combined--making medical errors the fifth leading cause of death in this country.

6. DURHAM, North Carolina (AP) -- A teenager from Mexico who mistakenly received organs from a donor with a different blood type was not expected to live more than a few days, a family friend said Tuesday. February 18, 2003

7. This was actually the second girl in several months to die after receiving a transplant with the wrong blood type This was actually the second girl in several months to die after receiving a transplant with the wrong blood type Dallas, 2002: A patient received a partial liver transplant from her father (type A) - but it was her mother who had compatible (type O) blood. Dallas, 2002: A patient received a partial liver transplant from her father (type A) - but it was her mother who had compatible (type O) blood. Laboratory mix-up was not detected until 19 days post-op Laboratory mix-up was not detected until 19 days post-op

8. “There’s more double-checking and systematic avoidance of mistakes at Starbucks than at most health-care institutions.” - Carolyn M. Clancy, Director AHRQ

9. “It is fundamental that the hospital shall do nothing to harm the patient … my view you know is that the ultimate destination of all nursing is the nursing of the sick in their own homes … I look to the abolition of all hospitals and workhouse infirmaries. But it is no use to talk about the year 2002.” Florence Nightingale Letter to Henry Bonham Carter circa 1867

10. U.S. Has Most Medical Errors 34% of US patients said they were given a wrong medication or dose, experienced a medical mistake in treatment, received incorrect test results, or had a delay in being notified of abnormal test results in the past 2 years. 34% of US patients said they were given a wrong medication or dose, experienced a medical mistake in treatment, received incorrect test results, or had a delay in being notified of abnormal test results in the past 2 years. 1/3 US patients had a physician visit in which their test results or medical records were unavailable, or a physician ordered a test that had already been done. 1/3 US patients had a physician visit in which their test results or medical records were unavailable, or a physician ordered a test that had already been done. Schoen et. al., Health Affairs Nov 3, 2005

11. Safety Conundrum Medical workers are expected to function without error. Errors are made by highly competent, careful and conscientious people for the simple reason that everyone makes mistakes every day. Lucian Leape, 1997

12. The “Blame Trap” Blame is universal, natural, emotionally satisfying, and legally convenient, it does nothing to make healthcare safer. -- Reason, 1994

13. Systems can be designed... To help prevent errors To make them detectable so that they can be intercepted To mitigate them if they are not intercepted

14. Dialysis Chains: Top Patient Safety Issues Patient Falls Medication Errors Access-Related Events Dialyzer Errors Excess blood loss and prolonged bleeding

15. Risk of Hip Fracture Among Dialysis and Renal Transplant Patients Incidence of hip fracture in dialysis patients: 2.9/1,000 patients/year Extrapolation to national incidence: 800 hip fractures each year in dialysis patients. December 18, 2002

16. Pharmacists on Rounding Teams Reduce Preventable Adverse Drug Events in Hospital General Medicine Units Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA Arch Intern Med. 2003 (Sept); 163:2014-2018 Medication Errors: Major Safety Issue in Hospitals

19. Health & Safety Survey Project: Patients & Professionals Funding by Abbott Laboratories & CMS Special Project Partners Sponsors

20. Patient Survey Invitations to participate in an anonymous survey sent to 3,587 patients drawn from a representative national patient sample Network #1 implemented the patient selection and coordinated survey mailing and responses Surveys completed by 1,762 patients

21. Patient Survey Sample Characteristics Mean Age 64 yrs. Gender: 54% males Race: 67% Caucasian, 28% African Amer. Dialysis Type: all in-center hemodialysis Vascular access: 21% catheter

22. Professional Survey Invitations to participate in an anonymous web-based survey widely distributed by RPA, Networks, Professional Meetings Web-based Surveys completed by 649 professionals

23. Percent ESRD Patients & Survey Respondents by Network

24. Patient Falls: Patients’ View Patient Survey last 3 months: 95% patients had never fallen at the dialysis unit –5% fell: extrapolated nationwide – 15,240 falls 55 patients (3.1%) reported falls in the unit –Some had several falls – mean # falls 1.3 –Reason for falls: Feeling dizzy or weak: 60%

25. Patient Falls: Staff View Professional Survey: Past 3 months: Mean # falls 0.65 = –If presume 100 pts/nurse/yr, falls rate: 26/1,000 pts/yr –2002: Hip fractures 2.9/1,000 pts/yr Reasons for falls –Feeling dizzy or weak: 40%

26. Needle Insertion Patient Survey: Past 3 months: 46% patients report staff sometimes, usually or always has problems inserting needles –6% say the last time there were problems, staff tried to insert the needle more than 3 times before getting help –Additional 24% say staff tried 3 times before getting help

27. Medication Safety: Patients’ View Patient Survey: Past 3 months: Physician review of medications with patients –40% patients report that they discuss their meds with their doctor only “sometimes.”

28. Medication Safety: Staff View Professional Survey: Past 3 months 43% professionals report 1 or more instances of patient given the wrong medicine or medicine at wrong time 63% report patients fail to receive 1 of their meds at times 37% report that a patient is given wrong dose of a medication at least once Overall 77% staff indicate a patient had a medication omission or error in past 3 months

29. Handwashing: Patients’ View Patient Survey: Past 3 months: 11% of patients report seeing nurses or technicians who do not washing their hands or change gloves before touching their access site

30. Handwashing: Staff View Professional Survey: Past 3 months: 27% professionals reported observing staff fail to wash hands or change gloves before touching a patient’s access

31. Set-up Predialysis: Patients’ View Wrong Dialyzer Set-ups 17% patients reported problems with settings on their dialysis machine 3% wrong dialyzer set up for treatment 2% wrong dialyzing solution set up 3% patients report a treatment when weight not recorded 6% patients report a treatment when BP not obtained prior to treatment 86% Staff report a patient blood sample was not taken when ordered in past 3 months

32. Overall Assessment of Safety Patients: 27% patients have seen at least 1 medical mistake in past 3 months 16% patients say they sometimes feel unsafe at the dialysis center 49% patients sometimes, usually or always worry that someone will make a mistake

33. Overall Assessment of Safety Professionals 30% professionals said mistakes occur more than rarely 30% professionals said the last observed mistake was not trivial Medical mistakes are connected to failure to adhere to procedures (59% of staff reporting medical mistakes) Most believe their dialysis facility has a positive patient safety environment

35. Conclusions Patients worry about medical mistakes more than they experience them (49%) Most staff (87%) are aware that medical mistakes have occurred in past 3 months

36. Conclusions Medication errors recognized frequently by patients and staff Patient Falls remain frequent source of adverse events Handwashing is recognized as patient safety issue in dialysis units Correct dialysis set-up and predialysis procedures are safety issues Adherence to procedures is a major source of medical mistakes

37. What Can You Do? Wash your hands Review medications with your patients frequently Assess patients for risk factors for falls CMS new Conditions of Coverage require a Quality Assessment Performance Improvement Program – participate Help design a “culture of safety” in your unit