In-Depth Review

Patient and Facility Safety in Hemodialysis:

Opportunities and Strategies to Develop
a Culture of Safety
Renee Garrick,* Alan Kliger,† and Beth Stefanchik*

Summary *New York Medical

Patient safety is the foundation of high-quality health care. More than 350,000 patients receive dialysis in the College, Westchester
United States, and the safety of their care is ultimately the responsibility of the facility medical director. The Medical Center,
medical director must establish a culture of safety in the dialysis unit and lead the quality assessment and Valhalla, New York,
and †Hospital of Saint
performance improvement process. Several lines of investigation, including surveys of patients and dialysis Raphael, Yale
professionals, have helped to identify important areas of safety risk in dialysis facilities. Among these are lapses in University, New
communication, medication errors, patient falls, errors in machine and membrane preparation, failure to follow Haven, Connecticut
established policies, and lapses in infection control. The quality assessment and performance improvement
process should include a dedicated safety team to focus on specifically identified areas of risk and to establish Correspondence:
outcome goals guided by best practices and agreed-upon measures of success. A safety questionnaire can be given Dr. Renee E. Garrick,
New York Medical
to patients and staff and the responses evaluated to improve understanding of the prevailing attitudes and concerns College, Westchester
about safety. By sharing these results, openly acknowledging the challenges, and using a blame-free root cause Medical Center, 100
process to identify action plans, the facility can begin to establish a culture of safety. Woods Road,
Clin J Am Soc Nephrol 7: 680–688, 2012. doi: 10.2215/CJN.06530711 Valhalla, NY 10595.
Email: GarrickR@
wcmc.com

Introduction hand hygiene, and faulty machine and equipment dis-

In July 2008, the New York State Department of Health infection (7,8,15,16), have been associated with out-
received notification that over the preceding 6 months breaks of unusual biopathogens (8,9,13), as well as
three hemodialysis patients in one unit experienced a transmission of vancomycin-resistant enterococcus
hepatitis C seroconversion (1). In 2010, during a facility and hepatitis B and C viruses. The regulations and
survey in California, “dummy drip chambers,” safety guidelines for water quality, reuse, and infection
which increase the risk for air embolism, were used control are established and readily available (14,17).
on the treatment floor to quickly prepare the machines Other safety risks may not be as readily apparent,
for patient use (2). Both cases exemplified a departure and data-driven efforts have helped to identify and
from standard of care, and the medical directors and prioritize safety efforts. Initial studies by Holley (4) on
the governing bodies received citations. adverse events and medical errors in dialysis reported
These are examples of compromised safety in United an error rate of 1 in 733 treatments and noted access
States dialysis facilities. This review focuses on the events, medication errors, circuit clotting, and patient
application of safety principles to dialysis facilities. We falls as among the most common events. A survey re-
review the data on high-risk safety areas within dialysis port from the National ESRD Patient Safety Initiative
facilities and suggest strategies to improve patient compiled a ranked list of safety issues (18). The top five
safety. safety issues were as follows: (1) patient falls, (2)
medication errors (including deviation from dialy-
sis prescription, allergic reactions, and medication
Dialysis Safety Priorities omissions), (3) access-related events (clotting, infil-
Dialysis facilities are complex organizations that trates, poor blood flow, difficult cannulation), (4)
involve providers from multiple disciplines and use dialyzer errors (incorrect dialyzer or dialysate and
advanced technology to care for patients with multiple equipment-related sepsis), and (5) excess blood loss
serious illnesses. As organizations become more com- or prolonged bleeding.
plex, the possibility for error increases (3), and potential In 2006, the Renal Physicians Association (RPA), in
risks must be identified and prioritized. collaboration with dialysis patients, nurses, adminis-
Some risks are readily apparent in dialysis facilities trators, and the Forum of ESRD Networks, launched a
(4–6). Water quality, membrane reuse, and infection nationwide survey of dialysis patients and providers
control are key areas of safety risk, and adverse (6,19). The survey focused on safety and assessed the
events have been reported in each area (7–15). Infec- attitudes of dialysis patients and professionals to-
tion control risks, such as design flaws (9), inadequate ward safety. The structure and results of this health

680 Copyright © 2012 by the American Society of Nephrology www.cjasn.org Vol 7 April, 2012
Clin J Am Soc Nephrol 7: 680–688, April, 2012 Patient Safety and Hemodialysis, Garrick et al. 681

and safety survey are available on the RPA website

(http://www.renalmd.org/Patient-Safety). Table 2. Areas of safety risk
The patient sample was randomly drawn from the Renal
Management Information System maintained by Medicare Patient safety hazards
and included patients who had been undergoing dialysis for communication, documentation, and/or training
failures
at least 3 months. A total 1143 surveys (response rate, 32%)
failure to follow policy and procedure
were available for analysis (19). The patient survey was com- poorly designed/implemented policies and
pleted on paper. Twenty-six percent of the patients required procedures
help completing the survey, which was largely provided by lapses in infection control and surveillance (including
their spouse or family (81.8%). That help involved reading access, catheter and hand hygiene)
the questions and answers (43%), writing the results on the machine design flaws
survey (33.6%), or answering the questions (12%). In a sep- facility design flaws (including water purification
arate online survey of dialysis caregivers, responses were system)
compiled from 649 dialysis professionals (Table 1) (6). Patient safety events
The surveys have limitations. Although all ESRD Networks General safety events
patient falls
were represented in both surveys, the numbers of responses
medication errors
from the East Coast exceeded those from other regions, and Access-related issues
physicians had the lowest response rate. In addition, because clotting, poor blood flow
there was no incentive to participate, the professional difficulty with cannulation
respondents may represent those most interested in safety. needle dislodgment/bleeding from needle site
This bias might have yielded a more favorable view of prolonged bleeding
dialysis safety as compared with the larger population Equipment issues
of dialysis professionals. The RPA surveys do, however, failure of dialysis equipment
demonstrate the perspective and concerns of patients and failure of water/reuse equipment
caregivers and, together with other data, offer insight into
the safety hazards and events associated with dialysis
therapy. that can jeopardize patient and facility safety. Several
types of latent hazards exist, but these latent failures can
largely be grouped into two broad categories: failures of
Safety Hazards communication and failures of policies. Policy failures in-
As shown in Table 2, many safety risk areas have been clude content errors and failures of implementation and
associated with dialysis. Safety hazards are latent risks compliance.

Communication
Table 1. Renal Physicians Association Health and Safety Miscommunication has been documented as a key safety
Professional Survey respondents by role risk that has great potential for patient harm. Data from the
Joint Commission suggest that approximately 63% of sentinel
Percentage events are directly linked to communication failures (20). The
Role in Facility Number
of Total
RPA surveys (6,19) queried patients and professionals re-
Assistant garding their attitudes about communication issues.
administrative assistant 33 5.1 Among the professional respondents, 94% indicated it
or receptionist was “easy” or “very easy” to communicate with patients.
social worker 94 14.5 Among professional respondents, 63% said that patients
dietitian 37 5.7 most frequently communicated about treatment issues,
patient care technician 21 3.2 and about half of the respondents indicated that patients
other technician (e.g., reuse, 19 2.9 sometimes discussed concerns about safety (44%) and staff
machine) (48%).
physician assistant 0 0
However, when patients were asked how “comfortable
Nurse
nurse practitioner 12 1.8 they feel about discussing their problems,” about 20%
nurse 124 19.1 were “uncomfortable to somewhat comfortable” discussing
charge nurse 54 8.3 their care with a nurse, dietitian, or technician, and 20% said
nurse manager 160 24.7 the instructions they received from those staff were unclear
Manager or only somewhat clear. These data are especially notable;
facility administrator 112 17.3 several studies suggest that cognition and memory are im-
area manager 23 3.5 paired in patients with renal disease, particularly during di-
Doctor alysis (21–23). Other studies have demonstrated limited
medical director 26 4 health care literacy, independently influenced by ethnicity
medical doctor 26 4
and socioeconomic factors, among dialysis patients (24). To-
Total 649 100
gether, the data suggest that dialysis patients’ ability to
assimilate data during dialysis may vary, making commu-
Reproduced from Renal Physicians Association Health and
Safety Survey—professional respondents, with permission. nication failures an inherent risk for advanced kidney
disease. Other specialties have demonstrated that patient
682 Clinical Journal of the American Society of Nephrology

understanding of and participation in their care (which are patients (4,18,28,32–37). Age, diabetes, motor strength,
key barriers to safe care) can be improved by using visual medication use (including antidepressants), a failed walk-
(charts, videos, graphics) and reading level–appropriate ing test, previous fall episodes, and visual impairment are
written educational tools (25,26). From a safety perspective, all risk factors for falls (33–39). Fall prevention is impor-
the creation of toolkits for patients with both written and tant because the incidence of hip fracture with fall and the
graphic material about dialysis safety may help improve 1-year mortality rate related to a hip fracture are increased
outcomes. in the dialysis population (36). Cook and colleagues (33)
Miscommunication between dialysis staff and others can studied dialysis patients older than age 65 and demonstrated
also contribute to safety failures (26). Care transitions be- that 47% of patients fell during a 1-year period and 19%
tween providers and care settings provide prime opportuni- sustained injuries. In a separate prospective study, Desmet
ties for communication errors. These transitions are common and colleagues (34) reported that during 12 months, 12 of
among dialysis patients as they undergo access procedures, 380 dialysis patients (mean age, 70.9 years) experienced a fall
hospitalizations, and specialist consultations. Facilities with fracture, and the overall fall rate was 1.18 falls/patient-
should evaluate scripted communication guides so that vital year. This rate is many times higher than that in the non-
data are readily available and shared with providers. Pa- dialysis elderly population (0.32–0.7 falls/patient-year).
tients should have copies of their problems lists, medica- Episodes of orthostatic hypotension (decrease in systolic
tions, allergies, and other vital information. These should BP . 20 mmHg) after dialysis were tracked, and a detailed
be updated frequently, and patients should be educated to report was obtained for every fall. Most falls (82%) occurred
share copies with providers. at home. Falls tended to be more common during the first
half of the interdialytic interval; of note, however, neither
Failure to Follow Policies and Protocols postdialysis BP nor orthostatic hypotension was predictive
Failure to document and follow protocol are also key of falling.
latent safety hazards (5,27,28). A recent ESRD Network The RPA survey queried falls in hemodialysis units; 55
quality audit found that about 4% of the dialysis records patients reported falls at dialysis during the prior 3 months
did not correctly document the dialyzer used (5). In Penn- (19). The most frequent explanations for falls provided by
sylvania, failure to follow protocols represented almost 13% patients were dizziness or weakness, difficulty in transfer-
of the annual dialysis events reported (28). About 10% of ring, and tripping within the unit. About 40% of the time
patients responding to the RPA Health and Safety Survey the professional respondents stated they did not know the
indicated that during the prior 3 months, their BP and weight cause of the fall. Several strategies may help to reduce the
were not always measured before dialysis, and 13% of the risk for falls (34–39), including monitoring orthostatic BP,
professional respondents agreed that this had “sometimes” staff education, use of evidence-based tools for fall assess-
happened (6,19). Almost 60% of professionals said mistakes ment (such as assessment of gait and vision), gait assis-
in the dialysis setup (dialyzer or bath) had occurred in the tance for high-risk patients, controlling clutter, and use of
prior 3 months. Of note, patients noted these errors less fre- in-floor patient weight scales.
quently (6%). It is possible (although not definite from the
survey questions) that the error was caught before initiation Medications
of therapy; however, patients also could have been unaware Almost half of the RPA Health Survey patients reported
of the errors (6,19). In addition to clinical safety, failure to taking 6–10 medications daily, yet most patients reported
follow protocol has also contributed to technical mistakes only “sometimes” discussing all their medications with
and lapses in infection control (1,2,4–9). Among other risks, their doctor (19). In the 2008–2009 survey by the Pennsyl-
protocol departures can result in critical errors in dialysis vania Patient Safety Authority, medication errors were the
reuse, dialysate composition, and water purification, with most common event type (28.5%), and most of these were
catastrophic effects on an entire facility (7–13). errors of omission (48%) (28). Other studies (4,5,19,40–42)
Adherence to protocols can be improved by prominently have confirmed the risk for medication omission in dialy-
posting key portions of critical policies and procedures and sis. Regarding the types of errors, intravenous heparin
by using checklists, double sign-offs, and “red rules,” which (both omission and dosage) accounted for slightly more
must be followed exactly (29). Understanding patients’ atti- than 11% of the medication errors noted by the Pennsyl-
tudes toward their illness, educating them about machine vania Patient Safety Authority (28). Other errors involved
preparation and treatments, and encouraging their partici- such agents as erythropoietin, vitamin D, and antibiotics.
pation in their care may also improve outcomes (25,30). Surprisingly, more than half of the professional respon-
dents to the RPA safety survey believe that patients are
never given the wrong medications or are given a medi-
Dialysis Safety Events cation at an incorrect time (Figure 1).
Unlike safety hazards, safety events denote the actual In addition to medication errors at dialysis, these patients
occurrence of errors and mishaps that have compromised are at very high risk for medication errors when transitioning
patient safety. Safety events vary in magnitude of risk, but between care settings and providers (43–45). Dialysis patients
the goal is to anticipate any such events and prevent them. require complex multidrug regimens. Non-nephrologists are
often not well versed about the types of medications and the
Patient Falls restrictions and dosing changes required by dialysis patients.
The majority of dialysis patients are older than age 65 For example, in a study of percutaneous cardiac interven-
(31), making the risk for fall more prevalent. Earlier stud- tions, despite clearly labeled warnings, 22.3% of dialysis pa-
ies have demonstrated an increased risk for falls in dialysis tients received medications that were contraindicated or not
Clin J Am Soc Nephrol 7: 680–688, April, 2012 Patient Safety and Hemodialysis, Garrick et al. 683

Figure 1. | Frequency of medication errors as reported by dialysis professionals. Used with permission from the RPA Health and Safety Survey.

recommended (enoxaparin and eptifibatide) and sustained (19), and access interruptions accounted for 6% of incidents
high rates of major bleeding complications (46). Strategies to reported to the Pennsylvania Patient Safety Authority (28).
minimize medication errors include frequent review of pa- Arterial and venous pressure alarms on dialysis machines
tients’ medication lists, educating patients to share their list are not sensitive enough to detect a partial dislodgment, and
with each provider, medication reconciliation when care set- rapid blood loss can occur at the typical blood flow rate.
tings change, and pharmacist participation in medication re- The Veterans Affairs National Center for Patient Safety
view (40–45,47). found that 40 of 47 bleeding episodes analyzed between
2002 and 2008 were related to venous needle dislodgment
Access-Related Events (51). Patient agitation and dialysis performed outside the
Thirty percent of patients responding to the RPA health main unit were major risk factors. Some of these resulted
survey indicated that staff tried more than twice to insert in patient death. As a result, all Veterans Affairs dialysis
needles before getting assistance, and 39% reported pain at centers now use a Food and Drug Administration–approved
the needle site. Of note, the majority of patient care technicians access alarm for all patients with venous needle access un-
and nurses indicated that they “rarely or never” had difficul- dergoing hemodialysis outside the treatment unit (51). Cath-
ties inserting needles, and two thirds indicated that after two eter access clamps that secure the access hub to the dialysis
attempts they called for assistance. Most staff said that a pol- tubing are also available (52). Other access-related safety
icy on difficult cannulation did not exist or that they were not issues include failure to cap catheter ports, failure to ad-
familiar with the policy (6,19). Access infiltration (usually at equately clamp access lines, and prolonged access bleed-
the initiation of therapy) represented 6.1% of the adverse di- ing after dialysis (6,18,28,51). Dialysis safety teams should
alysis events reported to the Pennsylvania Patient Safety Au- ensure that their policies and procedures articulate that
thority during a 1-year period and 31 of the 88 adverse events the access must remain visible throughout the treatment.
reported over an 18-month period by Holley (4,28). In a Moreover, industry should develop access needle moni-
study by Lee and colleagues, major fistula infiltrations lead- tors that are intrinsic to the dialysis circuit.
ing to additional intervention (including catheter placement)
occurred at an annualized rate of 5.2% and were more com- Hygiene Issues
mon with new fistulas (,6 months old) and in older patients Improper hand and glove hygiene were also troubling
(47). Strategies that include clear access policies and trained findings of the RPA safety survey. Over a 3- month period,
needling teams for new fistulas might reduce risk. about 10% of patients and 25% of staff reported that
Dislodgement of the access needle and catheter discon- infection control surrounding access was not always
nections are potentially life-threatening events (48–51). followed. The risks engendered by this behavior are clear
Five percent of patients in the RPA safety study reported (14–16,53), and it is a crucial issue for the facility quality
that the needle dislodged before completion of therapy committee.
684 Clinical Journal of the American Society of Nephrology

Dialysis Machine Errors and Events found that equipment failures per se were rare. Equipment
Fifteen percent of patients in the RPA safety survey problems accounted for about 4% of the adverse dialysis
reported that treatment was ended early because of problems events reported to the Pennsylvania Department of Health
with the dialysis equipment (Figure 2), and 20% reported (28). Surprisingly, 17% of the professionals responding indi-
that the machine clotted during treatment (19). Holley (4) cated that in the prior 3 months a machine was stopped
reported similar data on clotting of the dialysis circuit but before the scheduled completion time (Figure 3) (6).

Figure 2. | Occurrence of each event during dialysis in past 3 months as reported by dialysis patients. Used with permission from the RPA
Health and Safety Survey.

Figure 3. | Percentage of nurse and doctor respondents by frequency of events occurring during dialysis. Used with permission from the RPA
Health and Safety Survey.
Clin J Am Soc Nephrol 7: 680–688, April, 2012 Patient Safety and Hemodialysis, Garrick et al. 685

Attitudes toward Safety to develop process improvements and establish a culture of

About 75% of the patients and almost 90% of professional safety. The key elements of a culture of safety are outlined in
respondents to the health and safety surveys said they would Table 4. Critical among these is the understanding that
report a medical mistake, and 92% of patients indicated that it even a “safe” organization is not error-free. Instead, safe
was “easy or somewhat easy” to get help whenever a prob- organizations anticipate “what-if” events and avoid blaming
lem arose. Despite these findings, almost half of the patients adverse events on an individual’s failure. Root cause analy-
who responded indicated that they worry someone will sis is used to discover the system and process issues that
make a medical mistake during their dialysis treatment (Fig- contribute to adverse events. The goal of a root cause anal-
ure 4), and 16% of respondents indicated that some things ysis is to determine what happened, why it happened, and
make them feel unsafe at the dialysis center. Patients were what to do to prevent it from happening again (54). This
specifically asked about their level of involvement and analysis examines the policies, processes, and human factors
knowledge regarding their dialysis treatments; their beliefs (such as staffing ratios, experience, training, distraction, and
about the safety of their dialysis unit were not influenced by fatigue [55–59]) that can contribute to an event.
their self-reported level of involvement in their care (6,19). A culture of safety, void of “blaming” behavior, does
Of professional respondents, 70% indicated that mistakes not obviate individual accountability for competent, ap-
had never or rarely occurred during the past 3 months. The propriate care. If a dialysis caregiver neglects to follow an
majority of professionals reported a “very low” likelihood established process or procedure or behaves in ways that
that a medical mistake harmful to a patient would be made endanger patients, then peer review, remediation, and
at their center (6). These findings contrast with the Pennsyl- disciplinary action may be required. A robust safety sys-
vania Patient Safety Authority’s analysis of events by harm tem includes both individual peer review and system root
score (which assesses how often the event reached the patient cause analysis.
and the risk for harm to the patient) (47). That analysis dem-
onstrated that 5.5% of the events that reached their dialysis The Quality Improvement Process
patients resulted in harm (28). As was found in other sur- The 2008 Centers for Medicare & Medicaid Services (CMS)
veys (28), the majority of professionals in the RPA health Conditions for Coverage for End-Stage Renal Disease provide
and safety survey believe that medical errors were related specific guidance concerning safety in the dialysis setting (60).
to failure to comply with existing policies rather than The medical director is specified as the leader of the multi-
to the lack of staffing, equipment, or an adequate quality disciplinary quality assessment and performance improve-
program. ment program (QAPI) and is charged with establishing a
culture of safety and quality (CMS interpretive guideline
tags V710-716) (60–62). In corporation-managed or -owned
Developing a Culture of Safety facilities, the CMS regulations hold the facility governing
Elements of a Culture of Safety body responsible for allocating staff and resources for
The findings of the RPA health and safety surveys, sum- the QAPI program (CMS interpretive guideline tag V756).
marized in Table 3, together with the other data presented, The medical director, who is expected to have “some author-
illustrate that the dialysis setting presents potential ity to individualize corporate policies to address unique fa-
threats to patient safety. These areas offer a starting point cility situations” (CMS interpretive guideline tag V714), is

Figure 4. | Percentage of patient respondents by frequency of worry about occurrence of medical mistakes. Used with permission from the
RPA Health and Safety Survey.
686 Clinical Journal of the American Society of Nephrology

Table 3. Summary findings of Renal Physicians Association health and safety surveys

Safety Issues during the Prior

Professional Staff Response (%) Patient Response (%)
3 Months

Patients worried or concerned Patients communicated concerns Sometimes or always worried: 49

about safety/staff sometimes or always: 63
Ease of communication Easy to communicate with patients: Uncomfortable/somewhat uncomfortable
94 communicating with staff: 18
BP or weight not recorded Happened sometimes: 13 Happened sometimes: 10
prior to dialysis
Mistakes in membrane or bath Happened sometimes: 60 Happened sometimes: 6
set up
Lapses in infection control Reported event occurred: 27 Reported event occurred: 11
(hand hygiene)
Medication errors Missed or incorrect dose occurred Always discussed all medications with
sometimes: 23 staff: 23
Difficulty with access needles Rare or no difficulty inserting: 66 Pain at access site during treatment: 39
Prolonged access bleeding Sometimes: 15 Sometimes: 23
Needle dislodgement prior to Sometimes occurred: 4 Reported event occurred: 5
end of treatment
Medical mistakes in prior Reported no events occurred: 70 Reported no events occurred: 73
3 months

Used with permission from the RPA Health and Safety Survey.

Facility Safety Committee

Table 4. Elements of a culture of safety CMS regulations clearly stipulate that patient and facility
safety must be addressed as an integral component of the
Acknowledge the high-risk nature of the activity QAPI process. Facilities should create a dedicated safety
Establish safety as a key goal in policies and procedures team; as such teams can more reliably improve outcomes
Evaluate errors as “system failures,” not as an than can ad hoc efforts (64). Attitudes regarding safety can
individual’s failures
be disparate (65), and valuable information can be learned
Commit needed resources, including time and
technology by having patients and staff complete a safety questionnaire.
Recognize that a “safe” environment is not error free Such tools are available from the Agency for Healthcare Re-
Report “near misses” and events in blame- and search and Quality and the Five Diamond Patient Safety
retaliation-free environment Project, spearheaded by several ESRD Networks (66).
Develop processes for peer review and analysis of The team can evaluate safety risks and determine appro-
root cause priate priorities (such as falls, medication errors, and access
complications). Focused safety efforts are best accomplished
when well-defined measures of success are used to monitor
the effectiveness of each safety initiative. Safety teams should
held responsible for the direct oversight and the outcomes of
use specific strategies to improve care processes and reduce
the quality and safety programs. A data-driven QAPI
risk. For example, if compliance with protocols is a facility
plan must review both facility- and patient-specific out-
safety goal, the team might choose to implement checklists,
come data that focus on performance indictors that address
double sign-offs, or “red rules” and then remonitor adher-
medical errors, medical injuries, patient satisfaction, patient
ence. If a safety goal is not achieved, the interdisciplinary
safety, and infection control (CMS interpretive guideline
team must reevaluate the approach and seek new remedies.
tags V626-628).
A successful QAPI plan requires that data be reliably
collected and rigorously analyzed. One well accepted format Safety Resources
for this is the Plan-Do-Check-Act cycle (63). This method Excellent sites for general information focused on patient
begins with using available data and literature to “plan” safety include the National Patient Safety Foundation (67) and
the needed process improvements, which are then imple- the Agency for Healthcare Research and Quality (68). The
mented (“do”). The results are evaluated to determine Veterans Affairs National Center for Patient Safety (54) con-
whether performance has improved (“check”). If out- tains procedural information on root cause analysis, and the
comes improve, the results are shared and the new pro- World Health Organization has online safety courses and tools
cesses implemented throughout the organization (“act”), for tracking patient safety risks and outcome analysis (69).
and outcomes are reverified to ensure that the improve- Dialysis-specific information, including education modules
ments are effective and sustained. If the desired outcomes and a patient safety tool kit, is available at the RPA website,
are not achieved, then alternative or additional improve- which also sponsors the Keeping Kidney Patients Safe website
ments must be planned and implemented and the results (70). The Five Diamond Patient Safety Program (66) focuses
reanalyzed (63). on dialysis unit safety and promotes staff and patient
Clin J Am Soc Nephrol 7: 680–688, April, 2012 Patient Safety and Hemodialysis, Garrick et al. 687

education aimed at creating a culture of safety. The site contamination with vancomycin-resistant enterococci during
contains a comprehensive patient safety plan as well as ques- outpatient procedures and hemodialysis. Infect Control Hosp
Epidemiol 27: 287–293, 2006
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Plan-Do-Check-Act methods (5,66,71). cluster of bloodstream infections and pyrogenic reactions among
Our collective appreciation and understanding of the hemodialysis patients traced to dialysis machine waste-handling
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Acknowledgments strumentation. Standards. Available at: http://www.AAMI.org/
The Health and Safety Survey was sponsored by the Renal Physi- standards. Accessed April 12, 2011
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port. December 2001. A partnership between: the Renal Physi-
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Disclosures 20. The Joint Commission. Advancing effective communication,
None. cultural competence, and patient and family-centered care: a road-
map for hospitals. Available at: http://www.jointcommission.org/
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