Abstract: SA-PO0368
Trends and Causes of Incident Reports in an Ambulatory Hemodialysis (HD) Center
Session Information
- Dialysis: Epidemiology and Facility Management
November 08, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 801 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Delp, Crystal, SUNY Downstate Health Sciences University, New York, New York, United States
- Lwin, Yone Mee Mee, SUNY Downstate Health Sciences University, New York, New York, United States
- Mengal, Fida, SUNY Downstate Health Sciences University, New York, New York, United States
- Veerban, Fnu, SUNY Downstate Health Sciences University, New York, New York, United States
- Suraj, Fnu, SUNY Downstate Health Sciences University, New York, New York, United States
- Amjad, Arfa, SUNY Downstate Health Sciences University, New York, New York, United States
- Carter, Errol, SUNY Downstate Health Sciences University, New York, New York, United States
- Gruessner, Angelika C., SUNY Downstate Health Sciences University, New York, New York, United States
- Saggi, Subodh J., SUNY Downstate Health Sciences University, New York, New York, United States
Background
Increasing rates of ESRD due to obesity, DM, and hypertension, leads to more in-center HD—83.8% of new ESRD cases in 2023 (USRDS). Urban dialysis units treat up to 100 patients daily under tight staffing. Given that each dialysis machine circulates 500 ml of blood/min, safety is critical. Our goal was to examine incident trends, define causes, and identify areas to prevent escalating events in an outpatient dialysis setting.
Methods
We analyzed dialysis-related incidents reported in SUNY Downstate’s Safe Qual system from 12/1/2022 - 12/31/2023, including incident type, date, time, cause, and patient impact, with correlation to weekday, staffing, and resources. 29 incidents were reported (1.32 per 100,000 patient-years). Two incidents involved patient harm—one serious, one minor. Most incidents (29%) involved treatment delays from malfunctioning machines, and 43% were on Mondays.
Results
Most Monday incidents were related to equipment malfunctions causing delayed treatment starts, due to a backlog of unresolved equipment issues from weekends. Incident frequency were lower on days with less patients, with no correlation to staffing. Equipment examined after malfunction showed sediment buildup, raising concern about water quality.
Conclusion
We now perform immediate equipment repairs using in-house certified technicians. We’re working to install water filters to reduce sediment reaching the RO system. Staff training on timely incident reporting is ongoing. While limited by small sample size and single-center scope, the data point to equipment issues as a leading, preventable source of delays that impact patient care and satisfaction.