Patient Safety in Hemodialysis Care Delivery - a Commentary (Practice Corner) (Viewpoint Essay‪)‬

Hemodialysis, like other invasive health care treatments, is not without its risks. Patient care incidents and events are numerous and commonly seen and reported through event tracking mechanisms specific to individual programs or institutions. Examples of reportable incidents include medication errors (wrong patient, wrong medication, wrong dose, wrong time), breach of infection control practices, errors in dialysate composition, falls, and more. Quality assurance (QA) or Continuous quality improvement (CQI) programs are often an integral part of hemodialysis units yet, despite improvements, incidents and errors continue to be reported. Pressures related to time and staffing appear to have exacerbated the problem, leading to staff and administrative concern about this important issue (Tregunno et al., 2009). Numerous nursing-focused studies have been carried out that have demonstrated the impact of near misses and patient-level incidents related to patient health care. For example, Tregunno et al. (2009) conducted focus groups with direct care providers (nurses) and nursing leaders to examine the role of the latter in the prevention of patient-level errors. They revealed the need for a culture of safety--as defined by the nursing leader--that supports incident reporting while at the same time encouraging discussion without any fear of repercussions. The focus here is on using incidents and errors as opportunities for improvement and for learning, and not for blame.