Improving Incidents and Reporting in Dialysis Facilities

Improving Incidents and Reporting in Dialysis Facilities


Institutional Affiliation






Improving Incidents and Reporting in Dialysis Facilities


Patient safety is a critical subject in all healthcare institution. This is especially the case for dialysis facilities environment where it forms a topic of great concern for both the patients and the care providers. Oversight agencies such as the Centers for Medicare and Medicaid Services have continued to treat the matter with utmost seriousness as per their evident efforts. Although the healthcare community acknowledges that caring competent care providers face the risk of making errors, which forms one of the challenging aspects of being human. The aspect is highly costly as it poses a risk to the health of the patient, quality of medical care (Bear, and Stokie, 2014). It is important for the management to adopt and execute a policy pertaining to the continuous improvement of quality as it is considered effective in identifying the various factors that facilitate the occurrence of incidents and consequently putting in place measures that are aimed at preventing the incidents.

Literature Review

Patient Safety in the Dialysis Facility

According to Johnson (2015), the dialysis environment is prone to a wide range of factors that cause patient injury. The dialysis environment is a highly complex one that is characterized by the use of chemicals, drugs, equipment, and physical activity. The underlying processes are highly intricate and risky and when the situation is characterized by time constraints and staffing challenges, the underlying causes and reasons behind injuries and errors in the dialysis environment become more apparent. Some of the common causes and reasons behind injuries in the dialysis environment include:

  • Errors when offering medication whereby the care provider provides the patient with inappropriate medication;
  • Errors during the blood administration process;
  • Patient falls;
  • Malfunctioning of the medical equipment;
  • Exposure to the harmful chemicals;
  • Inappropriate record keeping;

A critical examination of each of the above root causes makes it possible to identify and develop practical and effective solutions to prevent patient injury and errors in the future.

Medication Errors

Rutherford, (2002) finds that in the healthcare realm, a medication error is defined as any preventable occurrence where a patient is administered with the wrong medication by a healthcare professional, consumer, or the patient him or herself. The occurrence may be as a result of errors in professional practice, procedures, health care products, and systems including wrongful order communication, prescription, product labeling, nomenclature, and packaging, dispersing, compounding, administration, distribution, monitoring, education, and use (Ulrich, & Kear, 2014).

Holder, (2005) identifies that the medical practice has advanced significantly over time and as a result, new drugs to treat diseases have also been developed. The myriad drugs administered in the dialysis facility further compound the level of risk for human, process, and system errors. At this juncture, it is prudent to highlight the five rights that form the foundation of drug administration that are normally taught in drug administration training. The five rights comprise of the right patient, the right time, right drug, right dosage, and the right route. It is highly possible for an error to take place when one or more of the above mentioned rights are not observed. The five rights are not necessarily sufficient in the prevention of medication errors but are effective at decreasing the levels of risk.

Blood Administration Errors

The dialysis process normally involves the administration of blood to the patient. It is important to take special consideration during the blood administration process. Before blood administration effective communication between the physical and the blood bank is critical in ensuring that the appropriate product is delivered. Equally important is to obtain the patient’s informed consent. The care providers should further adhere to the relevant facility policies and procedures to ensure that the proper patient is administered with the appropriate blood products in addition to monitoring the patient throughout the process. During dialysis, it is possible to administer blood to the patient in much rapid manner in comparison to other settings (Gupta, Cannon, and Srinivasan, 2013). Therefore, there is a higher level of risk of failing to observe the vital signs of the patient when the blood is being administered in a rapid manner. Additionally, the medical personnel need to inform the patient of any adverse effects resulting from an error during blood administration.

Patient Falls

Mc, Lennan (2013), finds that most of the dialysis patients are of advanced ages with the average age of the patients being 65 years. Older patients normally have co-morbid conditions that may have a negative impact on their ability to ambulate properly. The movements of such patients require the use of facilities such as wheel chairs and canes which eases there movement. Therefore, healthcare facilities are recommended to be well equipped with patient assist devices such as wheelchairs and canes to enable the patients move more effectively. Additionally, it is important to train the staff members on effective and safe patient transfer methods as they play a significant role in ensuring that the patient is transferred to the destined place in a safe way and consequently preventing the patient from incurring unnecessary injuries the dialysis environment also contains a wide range of liquid products. Liquid spills on floors further serve to increase the risk of patient and staff member falls. As a precaution, it is prudent for the concerned parties to identify wet floors and ensure that equipment for mopping out spills is readily available.

Equipment Malfunction

The dialysis process involves the use of highly sophisticated and delicate equipment. There are instances when such equipment malfunction and undergo maintenance problems resulting in serious injuries and patient deaths. In such an event, it is recommended that the matter is reported immediately to the relevant authorities such as the manufacturer and the Federal Drug Administration to facilitate the execution of the appropriate steps and prevent the occurrence of similar malfunctions in the future.

It is highly recommended that the administration ensures that all the lot numbers of all equipment are well documented. There have been many incidents where firms have ended up releasing faulty products to the market and hence tracking the lot numbers facilitates the easy identification of the faulty items and ensuring that they are not used in the dialysis environment.

Chemical Exposure

The dialysis environment contains highly hazardous chemical products and it is therefore, important to ensure that any chemical is handled in an appropriate manner. Common chemicals such as vinegar, dialysate, bleach, formaldhyde, and Renalin pose serious risk to injury and death in the event they are not handled in the proper manner. For instance, bleach is normally used to clean surfaces in the facility to prevent the spread and infection of blood borne pathogens (Karkar, Bouhaha, and Dammang, 2014). However, when it is mishandled and comes into contact with a person’s skin or other organ, it ends up causing serious injury.

Medical Record Errors

Record keeping in the healthcare facility plays a critical role in promoting efficiency and effectiveness in care delivery. Record keeping enables the care providers to store critical patient information and utilize it in the future. However, errors in record keeping pose serious implications for the patient. It is important to ensure that vital patient information is readily available: where in most cases it is recorded in a treatment flow sheet clipboard and placed near patient preferably at the bed. It is important for the medical personnel to have easy and ready access to the patient’s vital health information such as medication offered, allergies, and physical condition (Trent, 2016). Frequent audit exercises should be conducted in the administration to avoid unnecessary leave out of significant information. If the facility has adequate funds, it is advisable to computerize the treatment flow sheets to facilitate the efficient storage and access of patient information including that of those who are not admitted at the facility.

Research Methodology

The current research takes up the quantitative research methodology. Such research basically is meant to quantify the ,matters at hand by establishing numerical thjat which eventually is converted to reliable statistics. Therefore, by employing the quantitative research methodology, the study aims to identify a trend in the prevalence of incidents in the dialysis environment and in the process, offer some of the possible recommendations to reduce or prevent the identified incidents from occurring.


Study Design

The study design for the current study is the systematic review. The design mainly involves conducting a critical assessment and evaluation of the existing research studies that address the specific issue at hand. Using the approach, the researcher employed an organized technique of locating, assembling, and assessing the existing body of literature on the topic at hand through the use of specific criteria.

Discussion and Conclusion

In conclusion, the dialysis process is a highly intricate one that is characterized by a high level of risk. The risks can cause serious harm to the patient including fatalities. Some of the common causes of incidents include: Errors when offering medication whereby the care provider provides the patient with inappropriate medication; errors during the blood administration process; patient falls; malfunctioning of the medical equipment; exposure to the harmful chemicals; inappropriate record keeping. Ensuring patient safety and the decrease of incidents is the role of every stakeholder in the healthcare facility and should be steered by the top level management. The management should ensure that all members of staff take an active role in ensuring patient safety and observing the relevant policies and standards. Although the medical fraternity acknowledges that human beings are prone to making errors, it is equally acknowledged that the professionals are capable of observing the relevant standards and practices to decrease incidents of error.



Bear, R.A. and Stokie, S. (2014). Patient engagement and patient-centered care in the Management of advanced chronic kidney disease and chronic kidney failure. PubMed.Gov. 1:24. doi: 10.1186/s40697-014-0024-7.

Gupta, N., Cannon, M., and Srinivasan, A. (2013). National Agenda for Prevention of Healthcare-Associated Infections in Dialysis Centers. Seminars in Dialysis Journal. doi10.1111/sdi.12091

Karkar, A., Bouhaha, B. and Dammang, M. (2014). Infection control in hemodialysis units: A quick access to essential elements. Kidney Disease and Transplant Journal, 25(3), 496-519

Trent, J. (2016).  Improving Patient Safety in Dialysis Facilities. New York, NY: Palgrave Publishers.

Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456, 505.

Mc Lennan, S. (2013). The Handling of Medical Errors in New Zealand. Fehler Und Ethik in Der Medizin Neue Wege Für Patientenrechte, 339-345.

Holder, A. R. (January 01, 2005). Medical errors. Hematology. American Society of Hematology. Education Program, 503-6.

Rutherford, W. L. (January 01, 2002). Medical errors. The Pharos of Alpha Omega Alpha-Honor Medical Society. Alpha Omega Alpha, 65, 2, 50-1.

Johnson, G. (2015). Medical Errors. Bmj, 1, 218, 233-234.

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