Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 1
- Education and Training
- Human Factors Engineering 2
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 1
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 3
- Nonsurgical Procedural Complications 2
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Eran Kozer, MD; June 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.
Journal Article > 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.
This study demonstrated that laboratory-performed urinalyses were often inaccurate in comparison to those interpreted by nephrologists. The authors advocate for either greater training of this expertise among physicians or improved training among laboratory technicians to reduce the potential for diagnostic errors.
Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.
Russell S. San Francisco Chronicle. June 24, 2006.
This article reports on a Centers for Medicare & Medicaid Services report that details deficiencies in Kaiser's kidney transplant program.
Renal Physicians Association.
This Web site provides toolkits, educational modules, and an annotated bibliography to support quality improvement efforts for nephrology providers, and identifies best practice strategies for avoiding the Five Adverse Patient Safety Events in renal care.
Journal Article > Study
Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.
Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.
Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.
Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awareness of safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure, and describes techniques for clinicians to reduce risk of errors.
Journal Article > Commentary
Kliger AS. Clin J Am Soc Nephrol. 2015;10:688-695.
Failure to consider human factors and poor communication can contribute to dialysis treatment errors. This commentary discusses safety concerns in dialysis facilities, including medication errors, patient falls, and health care–associated infections. The authors recommend human factors engineering, patient engagement, and simulation as promising strategies to enhance safety in this setting.
Web Resource > Government Resource
Centers for Disease Control and Prevention.