Patient safety in chronic kidney disease: time for nephrologists to take action

Improving specialist drug prescribing in primary care using task and error analysis: an observational study

BACKGROUND

Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs.

AIM

To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS.

DESIGN AND SETTING

Semi-structured interviews with key informants followed by an observational study involving GPs in the UK.

METHOD

Twelve key informants were interviewed to investigate the use of CDSSs in the UK. Nine GPs were observed while performing case scenarios depicting requests from hospitals or patients to prescribe a specialist drug. Activity diagrams, hierarchical task analysis, and systematic human error reduction and prediction approach analyses were performed.

RESULTS

The current process of prescribing specialist drugs by GPs is prone to error. Errors of omission due to lack of information were the most common errors, which could potentially result in a GP prescribing a specialist drug that should only be prescribed in hospitals, or prescribing a specialist drug without reference to a shared care protocol. Half of all possible errors in the prescribing process had a high probability of occurrence.

CONCLUSION

A CDSS supporting GPs during the process of prescribing specialist drugs is needed. This could, first, support the decision making of whether or not to undertake prescribing, and, second, provide drug-specific parameters linked to shared care protocols, which could reduce the errors identified and increase patient safety.

Feasibility of a hemodialysis safety checklist for nurses and patients: a quality improvement study

BACKGROUND

Patients with end-stage renal disease are at high risk for medical errors given their comorbidities, polypharmacy and coordination of care with other hospital departments. We previously developed a hemodialysis safety checklist (Hemo Pause) to be jointly completed by nurses and patients. Our objective was to determine the feasibility of using this checklist during every hemodialysis session for 3 months.

METHODS

We conducted a single-center, prospective time series study. A convenience sample of 14 nurses and 22 prevalent in-center hemodialysis patients volunteered to participate. All participants were trained in the administration of the Hemo Pause checklist. The primary outcome was completion of the Hemo Pause checklist, which was assessed at weekly intervals. We also measured the acceptability of the Hemo Pause checklist using a local patient safety survey.

RESULTS

There were 799 hemodialysis treatments pre-intervention (13 January-5 April 2014) and 757 post-intervention (5 May-26 July 2014). The checklist was completed for 556 of the 757 (73%) treatments. Among the hemodialysis nurses, 93% (13/14) agreed that the checklist was easy to use and 79% (11/14) agreed it should be expanded to other patients. Among the hemodialysis patients, 73% (16/22) agreed that the checklist made them feel safer and should be expanded to other patients.

CONCLUSIONS

The Hemo Pause safety checklist was acceptable to both nurses and patients over 3 months. Our next step is to spread this checklist locally and conduct a mixed methods study to determine mechanisms by which its use may improve safety culture and reduce adverse events.

Development of a hemodialysis safety checklist using a structured panel process

BACKGROUND

The World Health Organization created a Surgical Safety Checklist with a pause or "time out" to help reduce preventable adverse events and improve communication. A similar tool might improve patient safety and reduce treatment-associated morbidity in the hemodialysis unit.

OBJECTIVE

To develop a Hemodialysis Safety Checklist (Hemo Pause) for daily use by nurses and patients.

DESIGN

A modified Delphi consensus technique based on the RAND method was used to evaluate and revise the checklist.

SETTING

University-affiliated in-center hemodialysis unit.

PARTICIPANTS

A multidisciplinary team of physicians, nurses, and administrators developed the initial version of the Hemo Pause Checklist. The evaluation team consisted of 20 registered hemodialysis nurses.

MEASUREMENTS

The top 5 hemodialysis safety measures according to hemodialysis nurses. A 75% agreement threshold was required for consensus.

METHODS

The structured panel process was iterative, consisting of a literature review to identify safety parameters, individual rating of each parameter by the panel of hemodialysis nurses, an in-person consensus meeting wherein the panel refined the parameters, and a final anonymous survey that assessed panel consensus.

RESULTS

The literature review produced 31 patient safety parameters. Individual review by panelists reduced the list to 25 parameters, followed by further reduction to 19 at the in-person consensus meeting. The final round of scoring yielded the following top 5 safety measures: 1) confirmation of patient identity, 2) measurement of pre-dialysis weight, 3) recognition and transcription of new medical orders, 4) confirmation of dialysate composition based on prescription, and 5) measurement of pre-dialysis blood pressure. Revision using human factors principles incorporated the 19 patient safety parameters with greater than or equal to 75% consensus into a final checklist of 17-items.

LIMITATIONS

The literature review was not systematic. This was a single-center study, and the panel lacked patient and family representation.

CONCLUSIONS

A novel 17-item Hemodialysis Safety Checklist (Hemo Pause) for use by nurses and patients has been developed to standardize the hemodialysis procedure. Further quality improvement efforts are underway to explore the feasibility of using this checklist to reduce adverse events and strengthen the safety culture in the hemodialysis unit.

Potentially preventable hospitalization as a complication of CKD: a cohort study

BACKGROUND

Ambulatory care-sensitive conditions have been described as those that (if appropriately managed in an outpatient setting) generally do not require subsequent hospitalization. Our goal was to identify clinical populations of people who are at the highest risk of ambulatory care-sensitive conditions related to chronic kidney disease (CKD).

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

2,003,054 adults (including 238,747 adults with CKD) residing in Alberta, Canada, with at least one serum creatinine measurement between 2002 and 2009.

PREDICTORS

Estimated glomerular filtration rate and albuminuria categories, CKD status, demographics, and clinical characteristics.

OUTCOMES

Hospitalization with heart failure, hyperkalemia, volume overload, or malignant hypertension.

MEASUREMENTS

We used the Alberta Kidney Disease Network database, which incorporates data from Alberta Health, the Northern and Southern Alberta Renal Programs, and clinical laboratories in Alberta.

RESULTS

During a median follow-up of 4.1 years, 43,863 participants were hospitalized for heart failure; 6,274 participants, for hyperkalemia; 2,035 participants, for volume overload; and 481 participants, for malignant hypertension. All 4 conditions were more common at lower estimated glomerular filtration rates and in the presence of albuminuria. In the subset of participants with CKD, heart failure, hyperkalemia, and volume overload were associated most strongly with older age, diabetes, chronic liver disease, and prior heart failure. Malignant hypertension was associated with prior hypertension, aboriginal status, and peripheral vascular disease. Remote-dwelling participants were more likely to experience heart failure and malignant hypertension than those living closer to providers.

LIMITATIONS

No data for medication use or potentially important process-based outcomes for study participants.

CONCLUSIONS

Our findings suggest that future studies seeking to determine how to prevent ambulatory care-sensitive conditions in people with CKD should target remote dwellers and those with comorbid conditions such as concomitant heart failure and liver disease.