FP687MAKING CARE OF HAEMODIALYSIS PATIENTS SAFER: OUTCOMES OF THE UK RENAL ASSOCIATION PATIENT SAFETY PROJECT, 2007-2015

Abstract

Introduction and Aims: Patient Safety is a priority for healthcare. In the UK 10% of hospitalised patients are exposed to incidents that might cause harm, and half are preventable. The Renal Association Patient Safety Project was developed in 2007 to identify incidents and risks to renal patients and to formulate and share solutions. Methods: The strategy developed has been: A. Identification of incidents and risks from 3 sources: i. Reports from renal units (by email to the project lead), National Patient Safety Agency, Medicines and Healthcare products Regulatory Agency (MHRA), and NHS England; ii. Analysis of renal incidents from the National Reporting and Learning System (NRLS); iii. Surveys of renal unit clinical directors and lead nurses of key risks. B. The project has been led by a nephrologist without additional funding. C. Incidents and risks were analysed by the project lead, circulated to renal units by email, and solutions were shared by email. D. Outcomes have been presented at regional and national meetings, and reported in UK renal and nursing journals. E. The Renal Association (RA) now collaborates with the British Renal Society (BRS) to enhance multiprofessional involvement. F. A RA/BRS Patient Safety Committee and a patient safety website has been developed. Results: 101 incidents, risks, alerts and reports were circulated to renal units over 65 months; 56% were from equipment failure, (mostly dialysis machines and disposables, including manufacturing and software faults), and 36% were from technique failure or use error by renal staff. Incidents of haemolysis associated with water sterilisation by hydrogen peroxide, chloramine and chlorine have occurred, but also have occurred unassociated with sterilisation. A survey of water plants indicated inadequacies of water supply design, plant renewal and sterilisation protocols which lead to the creation of national water treatment guidelines. Supply failure of PD fluid and haemofiltration disposables stimulated development of National Supply Resilience guidelines. Data was reviewed from reported incidents, risks identified by renal units, and 94 renal incidents reported to the NRLS over 12 months causing severe harm (n=66) and death (n=28). A theme of haemorrhage and infection related to fistulae and dialysis catheters emerged. Venous needle dislodgement continues to be a concern, and is undoubtedly underreported, as are other causes of haemorrhage and infection. Of the severe harm/death incidents, 40% were due to management failure, (particularly delay in receiving medical or nursing care), 27% from falls, and 16% from pressure ulcers, indicating renal patients are susceptible to failure of standards of care. Conclusions: The Patient Safety Project has shown that risks and incidents are predominantly related to haemodialysis. Units should continue to focus on risks for haemorrhage and infection from vascular access. Analysis of incidents has led to creation of national guidelines. General standards of patient care and prevention of falls and pressure ulcers need to be emphasised. Continuing training is essential. Renal societies should continue to work with MHRA and dialysis industries to avoid device-related incidents. Patient safety is a multiprofessional responsibility, and links with the BRS, MHRA and the NHS England and Royal College of Physicians Patient Safety committees have been valuable. This strategy could be applicable to other countries and other medical specialties.