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Search results for "Nephrology"

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  • Nephrology
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Journal Article > Study

Error detection and recovery in dialysis nursing.

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

This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.

Journal Article > Study

Medication errors and patient complications with continuous renal replacement therapy.

Barletta JF, Barletta GM, Brophy PD, Maxvold NJ, Hackbarth RM, Bunchman TE. Pediatr Nephrol. 2006;21:842-845.

The authors identified errors associated with continuous renal replacement therapy and found that use of industry-prepared, rather than manually compounded, solutions minimized errors.

Journal Article > Commentary

Patient safety in the dialysis facility.

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

The author offers a 5-point plan to help recognize and prevent errors in dialysis facilities.

Journal Article > Study

Medication dosing errors for patients with renal insufficiency in ambulatory care.

Yap C, Dunham D, Thompson J, Baker D. Jt Comm J Qual Patient Saf. 2005;31:514-521.

The investigators analyzed electronic records and found that dosing errors were common in ambulatory care settings for patients with renal insufficiency. They conclude that computerized decision support systems should be implemented in ambulatory care.

Cases & Commentaries

Diffusion of Responsibility Leads to Danger

  • Web M&M

Thomas J. Balcezak, MD, MPH, and Ohm Deshpande, MD; October 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. Although they planned to place a hemodialysis catheter and start dialysis as soon as possible, the ICU was full and the patient was forced to "board" in the ED. On arrival to the ICU, 5 hours after the initial labs, the patient was hypotensive and unarousable. The patient went into cardiac arrest, was intubated, and received urgent treatment for hyperkalemia. The nephrologist arrived and was surprised the hemodialysis had not been started. The dialysis nurse had been told to start the dialysis after the patient arrived in the ICU but was unaware of the urgency of the situation.

Special or Theme Issue

Mistakes We Make in Dialysis.

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

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.

Journal Article > Commentary

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

Pauly RP, Eastwood DO, Marshall MR. Hemodial Int. 2015;19(suppl 1):S59-S70.

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.

Cases & Commentaries

Transition to Nowhere

  • Web M&M

Timothy W. Farrell, MD; April 2015

For a man with hypertension, prostate cancer, and chronic kidney disease hospitalized with acute kidney injury, discharge planning created numerous challenges. The inpatient team wanted a 1-week follow up, but the patient was new to this health system and had not yet seen a primary care provider. With the next available appointment in 6 weeks, the patient was instructed to call the urgent care clinic (which offered only same-day appointments) 1 week later. However, he never made it to the clinic and presented to the emergency department 2 weeks later with poorly controlled hypertension.

Cases & Commentaries

Two Wrongs Don't Make a Right (Kidney)

  • Spotlight Case
  • Web M&M

by John G. DeVine, MD; March 2015

A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.

Tools/Toolkit > Government Resource

AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.

Rockville, MD: Agency for Healthcare Research and Quality; January 2015.

Health care–associated infections are a known contributor to adverse events among patients on dialysis. Building on evidence and insights from clinicians, this four-part toolkit includes videos, assessment tools, and slide presentations regarding how to apply principles of teamwork, patient engagement, and safety culture to ensure dialysis centers provide safe care to patients with end-stage renal disease.

Book/Report

Patient Safety in Dialysis Access.

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

Maintaining safety in the dialysis facility.

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.

Journal Article > Study

Patient safety culture in nephrology nurse practice settings: initial findings.

Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476.

This study utilized AHRQ patient safety culture surveys to assess nephrology nursing practices across the country. The survey revealed an overall interest in patient safety and teamwork, but also identified numerous areas for improvements, including handoffs, infection control, and medication errors.

Journal Article > Commentary

Bullying: a hidden threat to patient safety.

Longo J, Hain D. Nephrol Nurs J. 2014;41:193-199.

This commentary relates how bullying and other disruptive behaviors remain a pervasive issue in health care. The authors describe its impact on safety culture and highlight six standards to help address behaviors that hinder communication and transparency.

Journal Article > 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.

In this study, communication between inpatient and outpatient dialysis units at discharge was highly variable.

Cases & Commentaries

Sloppy and Paste

  • Web M&M

Robert Hirschtick, MD; July 2012

An elderly man presented to an emergency department (ED) with new onset chest pain. In reviewing the patient's electronic medical record (EMR), the ED physician noted a history of "PE," but the patient denied ever having a pulmonary embolus. Further investigation in the EMR revealed that, many years earlier, the abbreviation was intended to stand for "physical examination." Someone had mistakenly copied and pasted PE under past medical history, and the error was carried forward for years.

Cases & Commentaries

A Painful Dilemma

  • Web M&M

Sara N. Davison, MD, MHSc; June 2012

A woman with end-stage renal disease, who often skipped dialysis sessions, was admitted to the hospital with fever and given intravenous opiates for pain. Because her permanent arteriovenous graft was clotted, she had been receiving dialysis via a temporary femoral catheter, increasing her risk for infection. Blood cultures grew yeast; the patient was diagnosed with fungal endocarditis, likely caused by injections of opiates through her catheter.

Journal Article > Commentary

Optimizing patient safety during hemodialysis.

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

This editorial discusses hemodialysis safety in the context of a concurrently published study [see link below]. The author describes how discoveries based on clinician experience can augment patient safety in this setting.

Journal Article > 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.

Increasing adoption of clinical decision support systems (CDSS) is driven by evidence that a well-designed system may impact provider behavior, medication safety, and patient outcomes. This study developed a framework to assess the clinical appropriateness of alerts, and applied the framework to alerts designed for patients with acute kidney injury. The authors identified rates of false positive alerts, alert overrides, provider non-adherence, and provider response appropriateness. Using their proposed framework, they advocate for systematic approaches to implementing and evaluating CDSS to optimize alert adherence and minimize alert overrides. A past AHRQ WebM&M commentary discussed integrating CDSS to improve medication safety.

Newspaper/Magazine Article

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

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

This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute to diagnostic error.

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