AHRQ Patient Safety Network

The Collection > Nephrology

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (2)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (3)

•Medication Safety (17)

•Medical Complications (4)

•Nonsurgical Procedural Complications (5)

Origin/Sponsor

•Europe (3)

•North America (22)

Resource Types

•Journal Article (21)

•Newspaper/Magazine Article (4)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (6)

•Active Errors (10)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (5)

•Legal and Policy Approaches (2)

•Error Reporting and Analysis (6)

•Communication Improvement (4)

•Human Factors Engineering (4)

•Specialization of Care (3)

•Logistical Approaches (1)

•Culture of Safety (2)

•Technologic Approaches (8)

•Education and Training (5)

Clinical Areas
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Nephrology

Target Audience

•Health Care Providers (21)

•Health Care Executives and Administrators (18)

•Non-Health Care Professionals (8)

•Patients (2)

Setting of Care

•Hospitals (12)

•Residential Facilities (1)

•Ambulatory Care (6)

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MULTI-USE WEBSITE

Keeping Kidney Patients Safe.

Renal Physicians Association.

COMMENTARY

Optimizing patient safety during hemodialysis.

Himmelfarb J. JAMA. 2011;306:1707-1708.

STUDY

A framework for evaluating the appropriateness of clinical decision support alerts and responses.

McCoy AB, Waitman LR, Lewis JB, et al. J Am Med Inform Assoc. 2012;19:346-352.

STUDY

Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.

Reilly JB, Marcotte LM, Berns JS, Shea JA. Jt Comm J Qual Patient Saf. 2013;39:70-76.

STUDY

A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit.

Galhotra S, Devita MA, Dew MA, Simmons RL. Qual Saf Health Care. 2010;19:e38.

STUDY

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

Terrell KM, Perkins AJ, Hui SL, Callahan CM, Dexter PR, Miller DK. Ann Emerg Med. 2010;56:623-629.

NEWSPAPER/MAGAZINE ARTICLE

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

ISMP Medication Safety Alert! April 8, 2010;15:1-3.

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

NEWSPAPER/MAGAZINE ARTICLE

Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.

Russell S. San Francisco Chronicle. June 24, 2006.

NEWSPAPER/MAGAZINE ARTICLE

FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.

ISMP Medication Safety Alert! Acute Care Edition. June 19, 2008;13:1-3.

STUDY

Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety.

Friedman AL, Lee KC, Lee GD. Am J Transplant. 2007;7:480-483.

COMMENTARY

XL or Smaller?

Kozer E. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Patient safety in the dialysis facility.

Kliger AS. Blood Purif. 2006;24:19-21.

STUDY

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

Tsai JJ, Yeun JY, Kumar VA, Don BR. Am J Kidney Dis. 2005;46:820-829.

STUDY

Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency.

Sellier E, Colombet I, Sabatier B, et al. J Am Med Inform Assoc. 2009;16:203-210.

STUDY

Error detection and recovery in dialysis nursing.

Wilkinson WE, Cauble LA, Patel VL. J Patient Saf. 2011;7:213-223.

NEWSPAPER/MAGAZINE ARTICLE

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.

Boodman SG. Washington Post. June 13, 2011:E1.

COMMENTARY

The Forgotten Drip

Josephson SA. AHRQ WebM&M [serial online]. January 2008.

COMMENTARY

Ordering of continuous renal replacement therapy in a computerized provider order entry system.

Oh SS, Sinclair-Pingel J, Feldott CC, Hargrove FR. Hosp Pharm. 2007;42:255–257.

COMMENTARY

A fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose.

Sim MT, Stevenson FT. J Med Toxicol. 2008;4:25-29.

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