Transcript Incidents And Risks In Renal Units Results from the Renal

Renal Association
Patient Safety Project
Paul Rylance
Royal Wolverhampton Hospitals
BACKGROUND
• 10% of patients in hospital experience
suffer from some type of patient safety
incident
– Up to half are preventable.
• 60% of incidents related to equipment are
as a result of failure of usage
• Patient Safety is an NHS priority
– NHS Outcome Framework Domain 5
OBJECTIVES
• Patient Safety project commenced June 2008
• Project lead (PBR)
– Pilot project with NPSA
– Established project via Renal Association
• Renal Association working with
– Renal units
– National Patient Safety Agency (NPSA)
– Medicines and Healthcare products Regulatory
Agency (MHRA)
– PBR appointed to Committee on Safety of Devices
• Identify and learn from incidents and risks
• Improve renal patient safety.
NPSA Incident Data Analysis
• NPSA data
• Estimated ~ 725 incidents/year occur in
renal units in England and Wales
– Result in death or potential death
– severe harm
– or moderate harm
• 10 or more / unit / year
– ? Significant underreporting
(n=55)
(n=120)
(n=550)
Incidents and risk-prone situations
reported
• 30 month period
• 31 incidents and 5 risks identified
• Circulated by email to renal unit clinical directors
and lead nurses.
• Source of information about incidents
– Renal units
– NPSA
– MHRA
(42%) - incl. nurses and technologists
(28%)
(30%)
• 17 were circulated as NPSA or MHRA alerts.
Incidents and risk-prone situations
reported
• The largest number of incidents (36%)
were due to failure of dialysis techniques
or dialysis machine usage
• Failure of dialysis machines
(19%)
• Failure of dialysis equipment or
disposables
(22%)
• Medication
(19%)
Failure of dialysis techniques
• Venous needle dislodgement
• Fatal Pulmonary Embolus from an attempt
to unblock an occluded arteriovenous
fistula
• Air embolism from haemodialysis catheter
disconnection
• Bleeding from an infected fistula needling
site
• Bleeding from removal of femoral line
Failure of dialysis equipment usage
• Setting excessive ultrafiltration on HD
• Lack of mixing of bicarbonate
haemofiltration bags (ICU)
• Nikkiso conductivity setting (Na 170)
• Fresenius dialysate line configuration
SURVEYS
Venous needle dislodgements
• Approximately 100 episodes of venous needle
dislodgment/year in the UK
– 1:100,000 dialyses
– One death
– 6.4% resulting in moderate/severe harm
• Report produced in conjunction with the Centre
for Evidence-based Prescribing (CEP)
concluded
– Blood-loss detector can be indicated for high risk
patients
– Cannot be justified for universal use
– Alternative alarm available (less expensive)
Electrical Safety of HD machines
• HD machines not required to be earthed
• Risk of electricution via dialysis catheter
causing cardiac arrest
• ? Could be a cause of some sudden
deaths on HD Need to change electrical
safety category of HD machines
• MHRA reviewing this risk
Bleeding from dialyser to line
connection
•
•
•
•
•
•
•
Home HD patients
Dialyser / HD machine behind patient
Inadequate connection made
Blood leak when plastic warms up
No machine alarm
? Technique training / position of patient
Plastic flexibility change
Manufacturing faults
•
•
•
•
Non-safe safety needles
PD clamps sold as HD catheter clamps
HD catheter cuff glue
Plastic changes
– dialyser to line connection
– ? Line kinking
• Dialysate concentrate composition /
labelling error
Haemolysis on Haemodialysis
• Haemolysis on haemodialysis has been due to
– Water sterilisation
• Hydrogen peroxide in hospital (including 1 death)
• Chloramine in community
– Kinking of dialysis lines
• Northern Ireland
• Fresenius alert
– Unknown causes.
Survey of water supplies and
sterilisation techniques
• Undertaken by a renal technologist
– Gerry Boyle (St. George’s)
How is the water supplied to the renal
unit?
Direct from Water Supply
company main feed
27%
Through Hospital Estates
pipe distribution system
Other
73%
Only a quarter
of renal units
have a direct
feed from the
water company
mains
If the water is supplied through the Estates
Department pipe system do you know what
chemicals are added?
Yes
No
43%
57%
Nearly half of renal units
don’t know what chemicals
are added
Also - No consistent lines
of communication between
Estate departments and
Renal Units
How old is the Water Treatment System that is
used to supply water for your Dialysis Unit?
3%
13%
7%
47%
17%
13%
0-1 years
2-3 years
4-5 years
6-7 years
8-10 years
11 years or older
Don't know
Half Renal
Unit water
systems are
more than 10
years old
No consensus of water testing
method or frequency
6%
8%
14%
No monitoring performed
Dip strips
Colorimeter using tablet/powder reagents
Colorimeter using liquid reagents
Electrode sensor (such as Chlorosense)
Sample sent to lab
Automatic on-line continuous sensor
22%
8%
42%
3% 3%
14%
14%
17%
49%
It is not monitored
Before each dialysis session
Once each day
Once each week
Once each month
Less frequently
As required
Working party to develop new standards for
water supplies to renal units and water testing
• Development of RA guidelines for water
treatment
• Water treatment equipment defined by
technologists
• Nephrologists and technologists involved
at beginning of contract
• Water treatment outside building and
facilities PFI
• Develop contact with NHS Estates
CONCLUSIONS
• Renal Association Patient Safety project has
facilitated
– Rapid sharing of incidents and solutions.
– Strong links with renal nurses and technologists
– Renal units may have 10 or more life threatening
incidents/year
– Underreporting undoubtedly underestimates the
incidence of incidents.
– Failure of dialysis techniques and equipment usage is
the greatest risk for patient safety
• Emphasises the importance of training.
Future developments
• Presentations
– BRS/Renal Association oral presentation
– Renal Nursing conferences (European/UK)
– Dialysis 2011 course
– Patient Safety 2011
– British Journal of Renal Medicine
– ? RCP Medical Specialities Board
Future Developments
• Use outcomes of the project to develop RA
guidelines
• Further develop links with other agencies
and DH departments
• Project overseen and responsible to RA
Clinical Affairs Committee
– Discussions with Graham Lipkin
– Additional nephrologist involvement
– Succession planning