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Kidney Week

Abstract: PO1094

Patient Safety in a Large Multinational Renal Services Provider Network

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Marron, Belen, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Silva, Israel Pereira, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Lucas, Carlos, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Török, Marietta, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Wollheim, Charlotta, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Akdeniz, Filiz, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Pearce, Suzanne H., Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Macario, Fernando, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
Background

Patient safety is considered of paramount importance under any qualified provision of care, but results from routine tracking of incidents have scarcely been reported, even when that may negatively impact survival.

Objectives
To analyze all types of incidents in a multinational renal service provider network during 2019.

Methods

For the last 10 years, our institution has tracked all incidents under a structured process program, as well as, educated our staff in the importance of proactively reporting and analyzing incidents in a quarterly basis at the clinic, by country and globally. Incidents are categorized in 4 different types: A-Patient related; B-Staff and visitors; C-Products and D-Equipment. Different incident codes are assigned to each type (up to 54). Communication to Health Authorities applies in accordance with local country regulations. “Serious incidents” are immediately notified to the Corporate Office and to each Country Medical lead.

Results

A total of 92.923 incidents (2.7 incidents/patient/year) have been reported during 2019 (higher than in 2018: 2.2). This means an increase of 20% in the total number of reported incidents. Total incidents/1000 treatments was 17.2 (12.2 patient-related incidents). Reporting follows a heterogeneous pattern among countries, being lowest in Argentina and highest in the UK. Top 5 reported incidents were as follows: Codes A15 (voluntarily shortened treatment) and A14 (Patient did not show up), both related to patient adherence to treatment, accounted for 36% of total incidents, vascular access (VA) complications (A4) for 10.2%, change of dialyzer and/or blood lines due to clotting (A2) for 8.5% and recurrent minor monitor malfunction (D1) for 7.6% of incidents. Codes related with unexpected death or cardiorespiratory arrest are not present among the total global top 10 incidents.

Conclusion

Detailed tracking of incidents and comparison between countries have potential to increase quality of care and patients outcomes. Room for improvement recently made the Corporate Medical Office to launch new strategies on VA management, anticoagulation and patient compliance, among others. This large series may help other institutions to better monitor and standardize patient safety on dialysis.