The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 58 Results

Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment.

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Farnborough, UK: Healthcare Safety Investigation Branch. March 2023.

Patients receiving hemodialysis are at risk of complications, including air embolus. This report describes how unfamiliar equipment and lack of standardized training contributed to the death of a dialysis patient due to air embolus. Safety recommendations include changes in medical education on how to handle uncertainty in clinical settings and amending dialysis guidelines to include risk of air embolus associated with unclamped central venous catheters.

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

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WebM&M Case February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network.

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US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.

Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

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Patient Safety Innovation April 7, 2022

Mobile health apps are becoming increasingly popular for patients and clinicians. This innovative study implemented a pharmacist-led mobile health based intervention to improve medication safety of patients following kidney transplant.

Delayed Diagnosis of Kidney Transplant Complications

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WebM&M Case February 23, 2022

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

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

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Walton E, Charles M, Morrish W, et al. J Patient Saf. 2022;18:e620-e625.

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.

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

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Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.

Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

Patient Safety in Home Dialysis

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Perspective on Safety April 28, 2021

This piece discusses how the program mitigates safety risks for in-home dialysis and the potential for in-home programs to greatly expand.

In Conversation With... José A, Morfín, MD, FASN

José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.

Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts.

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Shah SN, Amato MG, Garlo KG, et al. J Am Med Inform Assoc. 2021;28:1081-1087.

Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. Over a one-year period, this study found that medication-related CDS alerts associated with renal insufficiency were nearly always deemed inappropriate and were all overridden. These findings highlight the need for improvements in alert design, implementation, and monitoring of alert performance to ensure alerts are patient-specific and clinically appropriate.

Care Compare.

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Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal enables access to comparative quality and safety data from doctors & clinicians, hospital, nursing home, home health, hospice, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities to support informed consumer health care provider selection activities.

COVID-19 leads to increased need for dialysis machines.

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Mosley T. Here & Now. Boston Public Radio. April 27, 2020.

Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for treating patients with COVID-19 who also experience kidney failure and a lack of dialysis machines and the professionals to run them.

Complications of Vascular Access Procedures in Patients with Kidney Disease

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WebM&M Case November 27, 2019

Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.

Prevalence of medication transfer errors in nephrology patients and potential risk factors.

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Ebbens MM, Errami H, Moes DJAR, et al. Eur J Intern Med. 2019;70:50-53.

Patients are at risk for medication errors during transitions of care, which can result in patient harm. This study sought to identify risk factors for error in nephrology patients in the ambulatory care setting. Authors found that 68% of patients experienced a medication error and 71% of those were identified as having the potential to cause harm. Higher numbers of medications were also associated with medication errors.

A demonstration project on the impact of safety culture on infection control practices in hemodialysis

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Millson T, Hackbarth D, Bernard HL. Am J Infect Control. 2019;47:1122-1129.

A culture of safety is a key component to the success of a patient safety program. This study surveyed a large outpatient dialysis program to assess how safety culture and use of evidence-based infection prevention practices is associated with infection risk. The authors found that adherence to such practices resulted in reduction in blood stream infections and improved the safety culture of the program. A PSNet Primer on human factors expands on these concepts.

Achieving dialysis safety: the critical role of higher-functioning teams.

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Wong LP. Semin Dial. 2019;32:266-273.

Patients with end-stage renal disease are vulnerable to adverse events in dialysis. This commentary outlines a team-based approach to improving safety in dialysis care. The authors highlight the importance of multidisciplinary teamwork, accountability, and coleadership to develop high-functioning teams for safe dialysis.

Performing an inadvertent procedure.

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Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.

The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.

Diffusion of Responsibility Leads to Danger

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WebM&M Case October 1, 2018

An elderly man presented to the emergency department (ED) with decreased oral intake, fevers, confusion, and falling urine output. Laboratory test results revealed acute-on-chronic renal failure, and an ECG showed tall T waves, potentially a sign of severe hyperkalemia and a precursor of a dangerous arrhythmia. The ED physician initiated treatment for hyperkalemia, and the on-call intensivist and nephrologist agreed the patient needed urgent hemodialysis.

Making Dialysis Safer for Patients Coalition.

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Centers for Disease Control and Prevention.

Dialysis is a common procedure that carries risks if not performed correctly. This initiative represents a collective effort that aims to develop, share, and test a set of interventions and tools to ensure the safety of dialysis.

Mistakes We Make in Dialysis.

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Rodby RA, Perazella MA, eds. Semin Dial. 2016;29(4):253-328.

Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles in this special issue explore common renal replacement management strategies that may need to be assessed and redesigned to improve the safety of patients receiving dialysis.

Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting.

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Pauly RP, Eastwood DO, Marshall MR. Hemodial Int. 2015;19 Suppl 1:S59-70.

Treatments delivered in the home carry the potential for certain risks. This commentary examines the literature on dialysis-related incidents occurring in the home setting and presents a framework to help address avoidable adverse events in home hemodialysis.

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