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Abstract: PO1144

Types of Incidents (Patient Safety) Managed at Two Different Medical Levels 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
  • Pearce, Suzanne H., Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Akdeniz, Filiz, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
  • Macario, Fernando, Diaverum Renal Services. Corporate Medical Office, Hyllie, Mälmo, Sweden
Background

Patient safety programs need a well-structured organization to facilitate proactive and fair reporting, prompt evaluation analysis and timely feedback followed by measure implementation and auditing.

Objectives
To analyze all types of incidents in our network during 2019 by two different levels (Corporate and Country) of medical management alert.

Methods

Our institution has tracked all incidents under a structured process program for the last 10 years, according to 4 incident types (Patient related, Staff-visitors, Products and Equipment) and 54 subcodes. Incidents are considered as serious when they may be life-threatening or result in death, impaired body function/structure and/or are deemed serious based on appropriate medical judgment. 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, whilst different codes may generate alerts into Corporate or Country.

Results

92.923 incidents (2.7 incident/patient/year) were reported during 2019. Total incidents/1000 treatments were 17.2 (12.2 were patients related incidents). Causes for alerts at Corporate level (n=81) were cardiorespiratory arrest (26%); unexpected death (19%); seroconversion (9%); wrong disposable/dialyzer (9%); hemolysis (7%); severe hypotension (5%) and different mix codes (25%). Reported incidents at country level (n=831) were more than half ascribed to equipment [water supply, power failure and flooding (53%)], medication errors (35%), venous needle dislodgment (20%) and staff-visitors Injuries (4%).

Conclusion

Tracking of incidents have potential to increase quality of care and patients outcomes. Despite continuous efforts to get better results, there is room for improvement on better staff compliance with our standard operating procedures especially regarding medications and venous needle dislodgment risk assessment.