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Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. J Patient Saf. Epub 2021 Sep 28. doi: 10.1097/pts.0000000000000898.

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November 24, 2021
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2021;Epub Sep 28.

Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.

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Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. J Patient Saf. Epub 2021 Sep 28. doi: 10.1097/pts.0000000000000898.