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S 17 Parallel session
S 17 Safety in Dialysis
Grosser Saal, 28th September 2015, 9:00 – 10:30
Programme of the Session
GS: Jutta Balhorn (Germany)
Quality and Safety in Renal Care: Shared Responsibility among Health Care Professionals and Patients
O 40
Blood transfusion during haemodialysis - Safety first!
Nuno Gomes (Portugal)
O 41
Life threatening life line: two questions to ensure a safe dialysis journey
Bushra Azam (Israel)
O 42
How can nursing and technical departments improve safety and quality of care
Jorge Moutinho (Portugal)
Abstracts
GUEST SPEAKER
Quality and safety in renal care: shared responsibility among health care professionals and patients
J. Balhorn1
1Nephro-consulting, Hamburg, Germany
Background: Most dialysis patients in Europe are used to be treated a with high quality and in a safe setting. Nevertheless, many hazardous situation may occur leading to failures and dangerous consequences and sometimes even to a patients’ death.
It is the responsibility of everyone involved to be aware of possible hazards and to avoid them when ever possible.
The presentation highlights causes for errors and mistakes and suggests possible strategies to reduce or prevent them.
Failure are human, but it is important how we deal with them and what to learn out of them.
Objectives: Learn which situation may cause hazards to patients during dialysis an how to prevent them.
Implementation of failure management system and risk assessment.
Disclosure: No conflict of interest declared
BIOGRAPHY OF THE GUEST SPEAKER
O 40
Blood transfusion during haemodialysis - Safety first!
N. Gomes1, A. Martins1, A. Seabra1, L. Rosa1, J. Fazendeiro Matos1, M.T. Parisotto2
1NephroCare Coimbra, Fresenius Medical Care, Coimbra, Portugal; 2NephroCare Coordination, Fresenius Medical Care, Bad Homburg, Germany
Background: The safety of dialysis treatment and effectiveness of care are the major concerns of health care providers. This also comprises blood transfusion. Therefore, dialysis centres must ensure safe, clinically effective, and efficient blood transfusion.
Objectives: To promote the quality and safety of the transfusion process and recognise the critical points.
Methods: In order to ensure quality and safety of the blood component transfusion process, our dialysis unit established a supply agreement with the Portuguese Institute of Blood and Transplantation (PIBT).
A procedure for blood component transfusions and administration protocols were implemented to ensure first-class quality and compliance with all the legal requirements and safety regulations.
In order to ensure compliance and a safe transfusion of blood components, we provided training sessions to our staff.
Results: Transfusion of blood components involves numerous steps that must be strictly controlled to ensure patient safety and prevent adverse events. These steps are related to:
- The patient, including the assessment of physical condition and the need of blood; confirmation of the identification; informed consent for transfusion, and sample collection for pre-transfusion testing.
- Blood components, request in the PIBT; pre-transfusion testing, unit identification, suitable transportation and storage for the dialysis unit.
- The relationship between the blood component and the patient, i.e. identification before transfusion, administration, and documentation of results.
Conclusion/Application to practice: The implementation of appropriate protocols and a quality management system in blood transfusion improves the safety and efficacy of the transfusion process and ensures optimal use of blood components.
Disclosure: No conflict of interest declared
O 41
Life threatening life line: Two questions to ensure a safe dialysis journey
B. Azam1, K. Nira1
1Nephrology, Haemek Medical Center, Afula, Israel
Background: When needles dislodge dialysis can turn deadly. Fatal blood loss due to needle dislodgment has been described in literature and the media, but published reports present only the tip of the iceberg. Sharing incidents, risks, solutions and best practice contribute to patient safety.
Objectives: With a focus on safe high quality care, a quality improvement project was established to standardize procedures in the dialysis unit, and to educate staff and patients to the risks and safety measures to prevent needle dislodgement during a dialysis session.
Methods: Staff members attended an educational session and learned the practice recommendation to minimize the risk of needle dislodgement. Patients were required to read and sign an agreement of shared responsibility binding them to take part in active surveillance of their dialysis line and to ask the nurse two questions to ensure that the access and needles are taped by a standard protocol and that are visible to staff and patients at all times.
Results: Involving patients and empowering them to take part in active surveillance of their dialysis line proved to be eminent to reducing the potentially fatal complication of needle dislodgement.
Conclusion/Application to practice: Patients are scored according to a questionnaire and ranked by the risk of needle dislodgement to high, medium or low risk; the score is visible to the staff in every dialysis session. Vital signs supervision includes surveillance of the access sight. Patients continue to ask two questions to ensure a safe dialysis journey.
Disclosure: No conflict of interest declared
O 42
How can nursing and technical departments improve safety and quality of care
J. Fazendeiro Matos1, J. Moutinho2, C. Miriunis3
1NephroCare Portugal, Fresenius Medical Care, Porto, Portugal; 2Tecnhical Service Department, Fresenius Medical Care, Porto, Portugal; 3NephroCare Coordination, Fresenius Medical Care, Bad Homburg, Portugal
Background: Today, nursing and health care largely depend on active medical devices and measuring instruments that support the daily work of health care professionals.
Objectives: To identify areas where the joint assessment of both nurses and technicians could improve outcomes and availability of the equipment.
Methods: Retrospective analysis of the assessment and selection processes used for the validation of new active medical devices (AMD) and re-validation of currently used devices.The main focus of this analysis was on defibrillators, glucometers and thermometers.
Results: Comparison of the random method used for the selection of AMDs with the present method, i.e. assessment of the AMDs by technical engineers and nurses responsible.
The current method includes deep analysis of the devices with regard to: Ease of use, quality and accuracy of results, reliability, availability, operating and maintenance costs, etc.
Conclusion/Application to practice: Working as one team - the healthcare workers team - nurses and technicians can improve the outcomes of the organizations, both in terms of patient and economic outcomes.
Disclosure: No conflict of interest declared