In hemodialysis, the dialyzer and the dialysate bath are important parts of the treatment. The dialyzer acts like an artificial kidney, helping to remove waste and extra fluids from the blood. Different types of dialyzers, like low-flux or high-flux, are used depending on the patient's needs. The dialysate bath is the fluid that helps clean the blood during dialysis, and its components, like potassium levels, can be adjusted based on the patient's recent laboratory results. Settings such as the type of dialyzer, the potassium bath, and other machine adjustments are ordered by the doctor and can change from session to session depending on the patient’s condition.
During a routine dialysis session, I was caring for a patient who I am already very familiar with as he is a regular patient who undergoes treatment three times a week. Upon checking the machine of the patient, I observed that the dialyzer that our technician hooked to the machine is a low flux dialyzer. Upon checking the patient’s chart, I saw that the type of dialyzer for this patient was revised from low flux to high flux and the potassium bath was increased from 2 mEqs/L to 3 mEqs/L. I asked our technician to check the order as well. Once the revision was confirmed, he immediately changed the dialyzer and added another bag of KCl to the dialysate solution. In our unit, one small bag of KCl is equivalent to 1 mEqs/L. I reminded him and the rest of the team to always check the chart before starting the treatment. Based on familiarity, it would have been easy to assume that the patient’s settings are still the same. If I had relied on memory and not double-checked the machine and the current orders, the patient would have received an incorrect treatment, potentially leading to inadequate clearance or electrolyte imbalance.
By verifying the current orders on the patient’s chart, I was able to catch the changes in dialyzer and dialysate orders. I adjusted the setup as ordered, alerted the team about the changes, and reminded them to always double check the chart for any changes. As a result, the patient received the correct therapy safely.
My actions were guided by several evidence-based practices aimed at enhancing patient safety. First, verifying the dialysis settings and type of dialyzer before treatment aligns with the recommendations from the Institute for Safe Medication Practices (ISMP). According to MacDowell et al (2024), the ISMP recommends rational use of independent double checks involving two different nurses to prevent errors prior to administration of medications. While this recommendation targets medications, I believe that the principle behind it also applies to any high-risk process like setting up a dialysis. A dialyzer and dialysate baths are not considered medications but they are a part of a prescribed medical treatment and they directly affect the patient’s blood chemistry, fluid balance, and toxin removal. With that being said, setting up the wrong dialyzer or the wrong potassium concentration can cause serious consequences just like giving the wrong drug dose could.
Second, in a study by Albreiki et al. (2024), the Hemodialysis Safety Checklist or Hemo Pause Checklist was designed to be used collaboratively by nurses at every session. By utilizing a checklist to confirm the patient’s identity and hemodialysis settings, adverse events are reduced and the safety culture in the dialysis unit is strengthened. Evidence from surgical safety checklists promoted by the World Health Organization has shown that similar “time-out” or pause procedures improve patient outcomes by increasing attention to detail and promoting a culture of safety. The Joint Commission International (2018) also has the same recommendation which falls under the International Patient Safety Guideline #4l Ensure Correct Site, Correct Procedure, and Correct Patient Surgery. While this guideline focuses on surgeries, the principle can also be applicable to other high-risk procedures such as hemodialysis. The expectation in this guideline is that prior to starting a procedure, all requirements of the verification process have been completed and documented.
Lastly, communicating the updated settings to the team ensured that everyone involved in the patient’s care were aware of the changes. My actions reflected the JCI principle that effective handoff communication is crucial to patient safety.
If faced with the same situation again, I would further improve patient safety by strengthening the use of checklists and independent double checks of the dialyzer, dialysate bath, and hemodialysis settings. While doing a “hemo pause” as a team is ideal since it allows everyone to verbally communicate any updates to the prescription and promote better communication, I’m afraid that it won’t be practical due to time pressure. However, a structured written verification can be done where the nurse and technician can independently review and sign off on a short pre-treatment verification checklist before dialysis.
References:
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MacDowell, P., Cabri, A., & Davis, M. (2024b, December 15). Medication administration errors. PSNet. https://psnet.ahrq.gov/primer/medication-administration-errors
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Albreiki, S., Alqaryuti, A., Alameri, T., Aljneibi, A., Simsekler, M. C. E., Anwar, S., & Lentine, K. L. (2023). A Systematic Literature review of safety culture in hemodialysis settings. Journal of Multidisciplinary Healthcare, Volume 16, 1011–1022. https://doi.org/10.2147/jmdh.s407409
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Joint Commission International (JCI). (2018, May). JCI Accreditation Standards for Hospitals.
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Jain, D., Sharma, R., & Reddy, S. (2018). WHO safe surgery checklist: Barriers to universal acceptance. Journal of Anaesthesiology Clinical Pharmacology, 34(1), 7. https://doi.org/10.4103/joacp.joacp_307_16