P1554TYPES OF INCIDENTS MANAGED AT TWO DIFFERENT MEDICAL LEVELS IN A LARGE MULTINATIONAL RENAL SERVICES PROVIDER NETWORK. (6th June 2020)

• Record Type: Journal Article
• Authors: Marrón, Belén; Silva, Israel; Lucas, Carlos; Torok, Marietta; Wollheim, Charlotta; Akdeniz, Filiz; Pearce, Suzanne; Westesson, Ulf; Macário, Fernando
• Is Part Of: Nephrology dialysis transplantation. Volume 35(2020)Supplement 3
• Publication Date: 2020-06-06
• Subjects: Nephrology -- Periodicals; Hemodialysis -- Periodicals; Kidneys -- Transplantation -- Periodicals; Hemodialysis; Kidneys -- Transplantation; Nephrology; Periodicals; 616.61
• DOI: 10.1093/ndt/gfaa142.P1554
• Languages: English
• ISSNs: 0931-0509

Abstract

Abstract: Background and Aims: Patient safety programs need a well-structured organization to facilitate proactive and fair reporting, prompt evaluation analysis and timely feedback followed by measure implementation and auditing. To analyze all types of incidents in our network from Jan.1 st to Sept. 30 th, 2019 by two different levels (Corporate and Country) of medical management alert. Method: Our institution has tracked all incidents under a structured process program for the last 10 years, according to 4 incident types (Patient related, Staff-visitors, Products and Equipment) and 54 subcodes. Incidents are considered as serious when they may be life-threatening or result in death, impaired body function/structure and/or are deemed serious based on appropriate medical judgment. Communication to Health Authorities applies in accordance with local country regulations. "Serious incidents" are immediately notified to the Corporate Office and to each Country Medical lead, whilst different codes may generate alerts into Corporate or Country. Results: A total of 68.399 incidents (2.7 incident/patient/year) were reported during Q1-Q3 2019. Total incidents/1000 treatments were 17.1 (12.1 were patients related incidents). Causes for alerts at corporate level (n=65) were: cardiorespiratory arrest (28%); unexpected death (15%); seroconversion (9%); hemolysis (8%), severe hypotension (6%) and air embolism (3%). Reported incidents at country level (n=655) were almost half ascribed to equipment [water supply, power failure and flooding (41%)], medication errors (36%), venous needle dislodgment (19%) and Injuries (3%). Conclusion: Despite continuous efforts to get better results, there is room for improvement on better staff compliance with our standard operating procedures especially regarding medications and venous needle dislodgment risk assessment.