Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration. Issue 3 (27th April 2022)

• Record Type: Journal Article
• Authors: Walton, Edward; Charles, Maureen; Morrish, Wendy; Soncrant, Christina; Mills, Peter; Gunnar, William
• Is Part Of: Journal of patient safety. Volume 18:Issue 3(2022)
• Page Start: e620
• Page End: e625
• Publication Date: 2022-04-27
• Subjects: hemodialysis -- bleeding -- reporting; Patients -- Safety measures -- Periodicals; Medicine -- Practice -- Safety measures -- Periodicals; Medical errors -- Prevention -- Periodicals; 610.289
• DOI: 10.1097/PTS.0000000000000898
• Languages: English
• ISSNs: 1549-8417

Abstract

Abstract : Objectives: 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. Methods: 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. Results: 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). Conclusions: 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.