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Abstract: SA-PO615

Improving Medication Errors in Hospitalized Hemodialysis Patients

Session Information

Category: Dialysis

  • 801 Dialysis: Hemodialysis and Frequent Dialysis


  • AlShanableh, Zain, UPMC, Pittsburgh, Pennsylvania, United States
  • Rehman, Muhammad Ebad U., UPMC, Pittsburgh, Pennsylvania, United States
  • Shimko, Kristen, UPMC, Pittsburgh, Pennsylvania, United States
  • Rosenthal, Joshua, UPMC, Pittsburgh, Pennsylvania, United States
  • Viswanathan, Vignesh, UPMC, Pittsburgh, Pennsylvania, United States
  • DeSilva, Ranil N., UPMC, Pittsburgh, Pennsylvania, United States

The kidney is a key organ for the excretion of several medications and their metabolites. Medical errors relating to dosing and/or timing of medications in patients on hemodialysis (HD) may have serious adverse events. This project was designed to identify and prevent common medications errors in HD patients.


A quality improvement project was conducted at the University of Pittsburgh Medical Center Presbyterian Hospital from May 2021 to March 2023. Nephrologists identified HD patients and created a single Powerchart list to be electronically reviewed by a dedicated pharmacist who ensured appropriate dosing and timing of renally dosed medications. We included patients admitted to the hospital that were on HD, with acute kidney injury or end stage kidney disease. We excluded patients from units that had on-site dedicated pharmacists or evidence of HD held for more than one week.


A total of 1723 reviews have been completed on 668 patients. Our analysis revealed that 1065 medications were being appropriately dosed and 146 medications required interventions. Of those that required intervention, 125 medications were rescheduled to be given after dialysis and 21 medications required dose adjustment (chart 1). Common medications identified are demonstrated in chart 2.


Approximately, 12% of medications reviewed required an intervention for dose/timing adjustment and 10% were defaulted to be given prior to dialysis. A pharmacist, via electronic review, was able to reduce these potential errors and next steps may include utilizing Electronic Medical Records solutions to automate error reduction.

Chart 1

Chart 2