Topic: Questions to participants in a semi-structured interview

Order Description

Research question: what factors compromise patient safety for adults undergoing hemodialysis from the nursing perspective in HD unit in Saudi?
Aim of the study:
To explore the perceptions of nursing staffs towards patient safety for adults undergoing hemodialysis in HD unit in Saudi.
To understand what compromises patient safety for adults undergoing hemodialysis from the nursing perspective in HD unit in Saudi.

– I need 20 question to ask haemodialysis nurses regarding their beliefs, attitude and experience toward factors compromising patient safety.

factors compromise patient safety as below:
1- medication
2-communication
3- patient fall
4- failure to follow policies and protocols
5-ability of nurses to detect errors
6-machine errors
7-infection(hand hygiene- machine-access av fistual-prevention)
8-hypovolemia(hypotension-catheter leakage-access infiltration).

Nephrology Nursing Journal January-February 2014  Vol. 41, No. 1 41
Error Recovery by Dialysis Technicians
M
edical errors are a major
problem in healthcare deliv-ery. Over a decade ago, the
Institute of Medicine (IOM)
(2000) estimated medical error-relat-ed deaths exceed the combined num-ber of deaths in America attributed to
motor vehicle accidents, breast can-cer, and AIDS, and estimated that the
non-fatal morbidity from medical
errors injures a million patients annu-ally. The complexity of healthcare
practice has been proposed as one of
the major barriers to taming this
problem (Amalberti, Auroy, Berwick,
& Barach, 2005; Leape & Berwick,
2005). The complex nature of detect-ing and recovering from errors in
health care poses challenges for
healthcare professionals.
William E. Wilkinson
Lee A. Cauble
Vimla L. Patel
Continuing Nursing
Education
William E. Wilkinson, DrPH, JD, RN, CNN,
is Risk Manager, DCI Arizona, Tucson, AZ, and
Researcher, Arizona State University, Department
of Biomedical Informatics at Mayo Clinic Campus,
Scottsdale, AZ. The author may be contacted direct-ly via e-mail at [email protected]
Lee A. Cauble, BSN, RN,  is Nurse Manager,
DCI Desert Dialysis Center, Tucson, AZ.
Vimla L. Patel, PhD, DSc, is Senior Research
Scientist and Director, Center for Cognitive Studies
in Medicine and Public Health, The New York
Academy of Medicine, New York, NY.
Acknowledgment: This research was supported by
an award from the James S. McDonnell
Foundation (JSMF 220020152) to Vimla L.
Patel. Special thanks to Lawrence Brauer, Amy
Sussman, Machaiah Madhrira, Howard Lien,
Janet Umstead-Tobias, Julie Lightner, Bradford
Guidry, Laura Davis, Rachel Buck, Stephen
Mistler and Diana Petitti at various stages in this
study.
Statement of Disclosure: The authors reported
no actual or potential conflict of interest in rela-tion to this continuing nursing education activity.
Note:  Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 51.
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-ing nursing education requirements for certification and recertification.
Copyright 2014 American Nephrology Nurses’ Association
Wilkinson, W.E., Cauble, L.A., & Patel, V.L. (2014). Error recovery by dialysis techni-cians.  Nephrology Nursing Journal, 41(1), 41-50. Retrieved from http://www.pro
libraries.com/anna/?select=session&sessionID=2968
Experts are believed to make fewer errors than novices. Researchers in other domains
have shown that experts not only make less errors, they also detect and recover from these
errors better than non-experts. To investigate this phenomenon among dialysis techni-cians working in hemodialysis, we evaluated the ability of dialysis technicians to detect
and recover from healthcare errors. Two clinical cases with embedded errors were creat-ed by an expert nephrology nurse. Twenty-four dialysis technician subjects read the cases
aloud and then answered a set of related questions. Subjects’ error detection and recov-ery responses were scored against the clinical cases. We found that there was no signifi-cant difference between the ability of expert and non-expert dialysis technicians to detect
errors. However, expert dialysis technicians recovered from significantly more healthcare
errors than less experienced, non-expert dialysis technicians. This has implications for
training dialysis technicians in better error detection and recovery strategies.
Key Words:  Patient safety, hemodialysis, dialysis technician, medication errors,
quality improvement.
Goal
To study the detection and recovery of healthcare errors of dialysis technicians as a method
to improve patient safety.
Objectives
1. Discuss the concept of error recovery and its role in patient safety.
2. Discuss the ability of expert and non-expert hemodialysis technicians to detect and
recover from errors based on the results of this study.
3. Utilize this research to improve future technician education and continuing education
programs.
Hemodialysis is a complex spe-cialty area that requires focused train-ing and experience. Dialysis techni-cians provide direct care services to
patients with end stage renal disease
(ESRD) and are cost-effective, nursing
care extenders under direct nursing
supervision. Dialysis technicians are
required to learn specialty skills and
undergo extensive on-the-job training
because during treatment, patients can
suffer severe fluid and electrolyte im  -balances, or can develop cardiac, pul-monary, and other fatal complica-tions. Dialysis technicians provide ad  -ditional personnel required nationally
Nephrology Nursing Journal January-February 2014  Vol. 41, No. 1 42
Error Recovery by Dialysis Technicians
to meet dialysis treatment de mands
and reduce costs (Fields, 2010; Kirby
& Garfink, 1991; Wolfe, 2011). There
are more dialysis technicians than
nurses and doctors combined who
work in hemodialysis (Medical Edu -cation Institute, Inc., 2012).
Certification is required to work
beyond 18 months in the field
(Centers for Medicare and Medicaid
Services [CMS], 2008). Arizona pass -ed legislation requiring technicians to
be certified within two years of em -ployment. As of October 14, 2008, all
Arizona patient care technicians
(PCTs) are required to become certi-fied within 18 months of employment
as a PCT (Arizona State Legis lature,
2008; Levy, 2008). Not all certifica-tion examinations approv ed by states
are nationally recognized, and certifi-cation may only be valid within the
state in which it is administered.
Prior to 2008, training of PCTs
varied from facility to facility, and
even sometimes within large organi-zations lacked standardization. Under
the 2008 CMS Conditions for Parti  -cipation, V694 specifies the training
curriculum that must be included for
all PCTs (CMS, 2008). The training
program must include the following
subjects: principles of dialysis; care of
patients with kidney failure, including
interpersonal skills; dialysis proce-dures and documentation, including
initiation, proper cannulation tech-niques, monitoring, and termination
of dialysis; possible complications of
dialysis; water treatment and dialy -sate preparation; infection control;
safety; and dialyzer reprocessing, if
applicable. These eight areas have
been the foundation of the training
for all PCTs at DCI Desert Dialysis
since 1985. In addition to the didactic
portion of the training, PCTs undergo
a preceptor-led 8 to 12 weeks of clini-cal training. The preceptors are PCTs
with two or more years of experience
supervised by the nurse educator.
They have received training in adult
learning and demonstrated a willing-ness and ability to be leaders in the
clinic. Since 2003, the preceptors
have also been required to be certi-fied by a national certification pro-gram. The Certified Clinical Hemo -dialysis Technician (CCHT) adminis-tered by the Nephrology Nursing
Certification Commission (NNCC) is
the examination all have chosen at
this facility.
Though many, but not all, dialysis
technicians have substantial training,
accidental deaths of patients on
hemodialysis have occurred from dial-ysis care errors made by dialysis tech-nicians. In 2008, a 71-year-old female
patient on hemodialysis died because
a reused dialyzer still filled with steri-lant was connected to the patient with-out first rinsing out the sterilant; car-diac arrest and brain in jury occurred
(Moore, 2008). In 2005, a dialysis tech-nician did not properly tape a female
patient’s fistula access needle, which
was then covered up with a blanket.
Blood pooled underneath the patient,
and she exsanguinated (Fields, 2010).
In 1988, a 68-year-old patient on
hemodialysis died because a dialysis
technician in a New Jersey clinic gave
the patient lidocaine, an anesthetic,
instead of mannitol, used to increase
blood pressure (Palley, 1988).
Data collected by the Pennsylvania
Patient Safety Authority, a state
healthcare injury tracking system that
includes hemodialysis-related data,
illustrates the kind and frequency of
errors that occur in the care of
patients on hemodialysis. One recent
report by the Pennsylvania Patient
Safety Authority (2010) presented an
analysis of dialysis errors found in
Pennsylvania over a one-year period:
From November 1, 2008, through
October 31, 2009, Pennsylvania
healthcare facilities submitted 526
event reports involving hemodialysis
administration to the Pennsylvania
Patient Safety Authority. Medication
errors were the most common type
event submitted, representing almost
29% (n = 150) of all hemodialysis-related events. Other hemodialysis
administration events involved failure
to follow policy or protocol, such as
treatment set-up procedures (12.9%),
needle disconnection and needle infil-tration (6.1% for each category), and
falls (5.9%) (p. 87).
Preventing and mitigating care-giving errors to promote the safety of
patients on dialysis is a vital and inte-gral component of nephrology nurs-ing practice (Ulrich, 2004, 2007,
2008). “Without a doubt, our role as
patient advocates calls on us to do our
best to ensure patient safety” (Ulrich,
2008, p. 237). The few studies that
have looked at clinician error in
health care have generally focused on
physicians and not on front-line pro -viders, such as nurses, healthcare
aides, dialysis technicians, or medical
assistants (Rothschild et al., 2006).
Statement of the Problem
And Theoretical Framework
Dialysis technicians are the larg -est single category of hemodialysis
healthcare providers in the industry.
The large number of dialysis techni-cians substantiates the need to study
those healthcare errors related to
hemodialysis, which could be attrib-utable to dialysis technicians, to im -prove patient safety. The literature
shows that 10 years of experience is
required to establish competence to
become an expert (Leprohon & Patel,
1995; Patel & Kaufman, 2006;
Wilkinson, Cauble, & Patel, 2011).
Experts are believed to make fewer
errors than non-experts, yet current
research suggests experts still make
countless errors (Amalberti, 2001;
Patel & Cohen, 2008; Patel et al.,
2010; Reason, 2004). Experts have
also been found to detect and recover
from these errors better than non-experts (Nyssen & Blavier, 2006).
Experts make errors, but surpass non-experts theoretically with superior
error management strategies that help
them detect and recover from them
more effectively (Amalberti et al., 2005;
Armitage, 2009; Patel & Cohen, 2008;
Rasmussen, 2003; Reason, 1990).
Patel and Cohen (2008) outlined
three conceptual stages to describe
error recovery:  near miss ,  miss, and
adverse event due to an error in evolution.
A near miss happens when the regular
routine is violated, but the error con-dition can be terminated prior to the
happening of unintended conse-
Nephrology Nursing Journal January-February 2014  Vol. 41, No. 1 43
quences. For example, a dialysis tech-nician draws up a heparin loading
dose of 2000 units of 1000 units/mL
concentration heparin and discovers
before the heparin is given to the
patient that the heparin loading dose
should be 4000 units of 1000 units/
mL concentration heparin. The dialy-sis technician then redraws 4000 units
of the heparin to administer to the
patient who then receives the correct
loading dose of heparin (Patel &
Cohen, 2008; Patel et al., 2010). A
miss occurs when the erroneous
action is completed for an error to
potentially create an adverse outcome
yet none has happened. An example
of a miss category of error in evolu-tion occurs when a dialysis technician
connects a patient to a 2K dialysate
and discovers immediately after the
patient is connected to the dialysis
machine but before the patient is dia-lyzed that the order is for a 4K
dialysate. The dialysis technician then
disconnects the 2K dialysate and
reconnects the dialysis machine to a
4K dialysate so the pa tient is not dia-lyzed with the wrong potassium con-centration dialysate for the dialysis
time duration ordered (Patel &
Cohen, 2008; Patel et al., 2010). An
adverse event due to error in evolution
happens when an unwanted conse-quence occurs. For example, an
adverse event occurs when a patient’s
fistula access lines are reversed, the
treatment is completed, and the
patient’s blood is re-circulated so the
patient needs to be re-dialyzed. If an
error in evolution is detected and
recovered at the near-miss stage, it
can be stopped from developing into
an adverse event.
People generate mental schemata
in the error recovery process. Sche  -mata are mental tools that assist indi-viduals to cognitively manage situa-tions, events, and action sequences.
The reader is referred to Ericsson and
Simon (1980) and to Patel et al. (2008)
for additional information on the con-cept of schemata and the use of sche -mata in error recovery. Schemata
help filter out irrelevant information,
leaving the relevant information to be
useful for enhancing the effectiveness
and efficiency of an individual’s deci-sion-making process. Dialysis techni-cians form their internal schemata
from their own education, training,
and past experiences regarding com-plex dialysis treatment to provide the
care they give to their patients
(Leprohon & Patel, 1995). Dialysis
technicians use their internal schema-ta to prioritize and manage errors
they are able to detect and then re  -cover (Armitage, 2009; Janicik &
Larrick, 2005; Patel et al., 2010).
The purpose of this study was to
explore the ability of dialysis techni-cians to detect and recover from
healthcare errors covertly embedded
in dialysis-specific clinical care scenar-ios. We hypothesized that expert dialy-sis technician subjects (defined in this
study as those certified dialysis techni-cians with 10 or more years of dialysis
experience) would detect and recover
from more errors than the lesser expe-rienced, non-expert dialysis technician
subjects (defined in this study as those
with less than 10 years of dialysis expe-rience – whether certified as dialysis
technicians or not) as found in other
technical and professional fields. This
study was part of a larger study that
looked at the performance on error
detection and correction by nurses and
dialysis technicians (Wilkinson et al.,
2011). One part of this study with nurs-es showed performance with procedu-rally based error detection and recov-ery was significantly higher as a func-tion of expertise (p < 0.05). More
experienc ed nurses performed better
than the less-experienced nurses when
detecting and recovering procedurally
bas ed errors. However, no differences
were found between these groups for
knowledge-based errors (Wilkinson et
al., 2011).
Study Design and Methods
We conducted an empirical study
to determine if dialysis technicians
were able to detect and recover from
the number of embedded errors with-in two clinical case scenarios. The
clinical sites at which the study
occurred were part of a single nation-al dialysis care corporation. All dialy-sis technicians from five clinical dialy-sis settings in Southern Arizona were
invited to participate in the investiga-tion from June through August 2009.
Human subjects’ approval was ob -tained to conduct the research. Four
of the clinical locations were outpa-tient dialysis clinics, and one site was
an inpatient hospital setting. The five
sites were supervised by a single
administrator, and the staff rotated
working in other sites occasionally to
meet patient coverage and staff vaca-tion needs. The training of dialysis
technicians at the study locations was
overseen by one in-house masters-prepared nurse educator with three
de cades of nephrology nursing expe-rience. Dialysis technician training
included instruction with a core cur-riculum established by the national
dialysis corporation’s education de -partment and a concurrent 8 to 12-week, preceptor-led, on-the-job train-ing and evaluation component.
Clinical Case Scenarios
The clinical case scenarios were
developed under the direction of an
expert nephrology nurse who has
worked in hemodialysis for 34 years
and who was a nurse manager for one
of the chronic-care hemodialysis clin-ics in Southern Arizona. The two clin-ical scenarios reflected a composite of
realistic chronic care for patients on
hemodialysis and treatment events
that have happened or could happen
with any patient who receives hemo -dialysis treatments. Two other neph -rology nurses experienced in hemo&nbsp; -dialysis reviewed and validated the
clinical scenarios. The clinical cases
with the embedded errors in bold are
shown in Tables 1 and 2.
Clinical Case 1: Error
Detection and Recovery
There were five procedural er -rors. Procedural errors are defined as
errors made while performing dialysis
care that are derived from routine
schema-driven and protocol-driven
activities that are typically performed
by dialysis technicians. Procedural
errors incorporate both categories
Nephrology Nursing Journal January-February 2014&nbsp; Vol. 41, No. 1 44
Error Recovery by Dialysis Technicians
described in the human error litera-ture as rule-based errors (managed by
rules and procedures that may be
wrong or recalled inaccurately) and
skill-based errors (using mental mod-els of tasks automatically) (Leprohon
& Patel, 1995; Patel et al., 2010).
There were also knowledge-based
errors embedded within the two
cases. The knowledge-based error
information category required dialy-sis-specific nursing domain knowl-edge that would not be possessed by
non-licensed nursing trained person-nel. Consequently, though present in
the study cases, the knowledge-based
healthcare errors in the two clinical
cases, which were used additionally to
study nurses working in dialysis in
another study, were ignored for the
dialysis technician research compo-nent presented herein (Wilkinson et
al., 2011).
Three procedural errors involved
programming incorrect computer set-tings on the dialysis machine. Proce&nbsp; -dural Error 4, an incorrect potassium
concentration, was the most critical to
miss. Failure to detect and correct the
other errors could cause problems;
however, they were not necessarily
life-threatening.
Procedural Error 1: Using the
wrong dialysate. The first machine
programming error shows the time
listed in Clinical Case 1 to be 3.5
hours. The setting programmed into
the machine, which should be 3.5
hours as prescribed, is actually 3
hours and 50 minutes. This gives the
patient an extra 20 minutes of treat-ment instead of the 3.5 hours as pre-scribed. The 3.5 hours was translated
into 3 hours and 50 minutes. The pro-gramming for Procedural Error 1, the
time being extended by 20 minutes
from 3 hours and 30 minutes to 3
hours and 50 minutes, would not be
harmful to the patient under most cir-cumstances. If the amount of fluid
removed during the treatment was
increased during the extra 20 min-utes, a fragile patient could be affect-ed negatively either during the treat-ment or later at home after the treat-ment. The extra fluid loss could trig-ger electrolyte imbalance and pro-Table 1
Case 1 Text with Embedded Clinical Errors Bolded
Julia, a 61-year-old Hispanic woman, presents in triage with a two-year history
of ESRD, secondary to diabetes mellitus type II. She has a left UA fistula. There is a
thrill and bruit present per palpation and auscultation. Her vital signs are elevated with
blood pressure of 174/102, pulse 96, respirations 20. Her temperature is 96.7. She
complains of SOB and ankle swelling. Her EDW is 49.4 kg. The patient’s weight today
is 56.1 kg. Breath sounds are diminished bilaterally. She has 3+ edema in BLE. A sys-tolic murmur is audible. Julia is taken back to station 5 for hemodialysis (HD) after
being triaged. Her dialyzer is checked for her name.&nbsp; The dialysate bath is 4K, 2.5
Ca. Louise is assigned as her dialysis technician. The dialysis machine is pro-grammed to remove 4.2 kg of fluid over 3.5 hours of HD treatment. The red and
blue lines are both plugged into the wall outlets.Louise entered the following
machine settings: Flowrate 600, time 3:50, volume 42, heparin stop time 45 min.,
heparin rate 1500. Dialysis needles are inserted into the fistula with the red line above
and blue line below. Two hours into treatment, Julia has received the following med-ications: Epogen
®
4900 units, IV; Venofer
®
100 mg, IV;&nbsp; Zemplar
®
5 mcg; and
Calcitriol
®
3 mcg . Julia’s blood pressure has dropped to 96/48, and she is shouting
that both of her feet and legs are cramping. The patient is placed in minimum and
given 100 cc of normal saline IV. She improves immediately, and cramping abates&nbsp; for
over an hour . She then again complains of severe cramping, and 10 ml of 23.4%
saline is given IV.Julia completes her HD treatment, clamps are used to help her
blood clot, and she is instructed to return for her next treatment in two days.
Source: Wilkinson et al., 2011. Reprinted with permission from the Journal of Patient
Safety .
Table 2
Case 2 Text with Embedded Clinical Errors Bolded
Mason, a 53-year-old African-American male, came in for his usual tri-weekly
treatment. He has been on hemodialysis (HD) for two hours and 45 minutes of his
4.25 hours HD treatment run. Norma, Mason’s HD technician, shouts out, “I need
help over here now.” The charge nurse just left on break. The staff nurse notes
that Mason had 4.12 liters of fluid removed so far.&nbsp; The time is 10:46 a.m. The
patient is completely non-responsive to verbal questioning. The nurse notices
that the pupil in one eye is larger than the other. Attempts to arouse Mason by
shaking his shoulder are unsuccessful. A hypertonic is given via his catheter
access site.
Mason’s blood pressure is 222/134, and his heart rate is 92 and irregular.
It is Saturday and no other nurse is in the office. The charge nurse is across the
street in the kitchen on a late break because it has been a busy, hectic morning. The
nurse comes back to check on how Mason is responding to the hypertonic solution
given to him 13 minutes ago.&nbsp; The time is now 11:15 a.m. Mason’s condition has
not changed. He remains non-responsive, and his body is flaccid. The staff
nurse leaves Mason to get the AED. On the way to get the AED, the charge
nurse returns from break and the staff nurse tells the charge nurse what has
happened. The charge nurse calls 911. Paramedics arrive, and Mason is taken to
the nearest hospital emergency room and admitted. Mason died two days later from
a stroke he developed while on hemodialysis.
Source: Wilkinson et al., 2011. Reprinted with permission from the Journal of Patient
Safety .
Nephrology Nursing Journal January-February 2014&nbsp; Vol. 41, No. 1 45
duce muscle cramping and fatigue for
the patient.
Procedural Error 2: The vol-ume of fluid to be removed dur-ing the hemodialysis treatment.
The nurse who triaged the patient
directed that the dialysis machine be
programmed to remove 4.2 kg of
fluid (4200 mL of fluid). The error
embedded shows that the volume of
fluid programmed for removal was 42
kg. It would be deadly to remove 42
kg of fluid from any patient. The dial-ysis machine should catch and not
allow an error of that magnitude to
occur.
Procedural Error 2 was program-ming the machine to remove 42 kg of
fluid. The correct setting should have
been 4200 mL of fluid to be removed.
A setting of 42 kg would obviously be
too much (10 times the amount that
should have been removed). It would
be impossible to remove this amount
of fluid. Attempting to remove 42 kg
of fluid could cause harm to the
patient even part way through the
treatment. The harm caused could
include electrolyte imbalance, muscle
cramping, hypotension, nausea and
vomiting, and headache. In the worst
case, it could possibly result in a
patient’s death with severe dehydra-tion.
Procedural Error 3: The hepa&nbsp; -rin infusion rate per hour pre-scribed for the patient’s treatment.
The rate prescribed is 1500 units per
hour. The Braun machine does not
accept a rate calculated in the number
of heparin units. The machine re -quires programming of 1.5 mL per
hour. The rate shown in the scenario
is 1500, and it should be 1.5 mL. The
procedural error concerns incorrectly
cognitively converting heparin units
into mL/hour. This may be a Braun
machine-specific medical error.
Procedural Error 3 involved the
heparin administered during the
treatment. Overdosing of heparin
could prove a problem for the patient
and has been linked to fatalities in a
variety of settings. The proper setting
for heparin in this scenario would be
1.5 cc or mL per hour using 1000
units per 1 cc heparin. Heparin is
actually supplied in the clinic studied
in three dosage concentrations. The
first is 1000 units per 1 cc, the second
concentration is 5000 units per 1cc,
and the third concentration is 10,000
units per 1 cc. The obvious differ-ences in dosages are dramatic; this
could be a serious problem if not
detected and corrected by the clini-cian. After this study was conducted,
a policy change was made to pur-chase and utilize heparin only in the
1000 units per milliliter formulation.
The reasons for this change were
unrelated to the study.
Procedural Error 4: Use of the
wrong electrolyte concentrations
for the patient’s prescribed dialy&nbsp; -sate. Earlier in Clinical Case 1, it
states that the patient is ordered to
have a 4K, 2.5 Ca dialysate. The
dialysate of 4K has to be especially
mixed for this patient. The solutions
available in the wall outlets at this
clinic are limited to two concentration
selections of potassium solution levels
of only either 2K or 3K. Therefore, if
the dialysate is plugged into the wall
as stated in Clinical Case 1, the potas-sium could only be at a concentration
level of 2K or 3K, but not at a 4K
level. This is a potentially significant
medical error that can affect the car-diac muscle. Although outlet configu-rations and potassium concentrations
could vary in specific clinical setups,
the error here should be obvious to
every practitioner, especially due to
its potential injury severity to the sub-jects studied in the outpatient clinic
study sites.
The fourth procedural error in -volves connecting the dialysate to an
improper potassium concentration
solution. This could be a very serious
error, and the consequences can
range from tachycardia to bradycar-dia, myocardial infarction, heart
attack, or even death. The blood
maintains potassium levels within a
narrow range normally between 3.5
and 5.0 mg/dL. Either a very high or
excessively low serum potassium
level could result in death to the
patient.
Procedural Error 5: The inser-tion of the needle direction into
the fistula site.&nbsp; In Clinical Case 1,
the fistula needle insertion description
states that the blue line is inserted
below, and the red line is inserted
above. This is reversed, and typically
the blue or venous line is the upper
needle in the fistula and the red or
arterial line is referring to the lower or
bottom needle insertion site. This
configuration results in recirculation
of the blood.
The fifth and final procedural
medical error embedded within Clin -ical Case 1 concerns the reversal of
the direction of blood flow in the fis-tula by connecting the arterial line to
the venous side of the fistula and the
venous line to the arterial side of the
fistula. This would result in recircula-tion of the blood flow, and there
would be little or no dialysis occur-ring for the patient to remove waste
products from the bloodstream and
balance electrolytes. The outcome of
this error is in the patient not receiv-ing the benefit of dialysis from the
treatment while believing that the
blood had been dialyzed properly.
Clinical Case #2: Error
Detection and Recovery
There were two procedurally
based errors in Clinical Case 2.
Procedural Error 1: The charge
nurse should have been called
back immediately for help with a
non-responsive patient. The first of
the two embedded procedural patient
care errors in Clinical Case # 2 was
that the staff nurse should have called
the charge nurse back right away
when the non-responsive pa tient was
discovered. This patient problem was
serious enough that the charge nurse
should have been notified without
delay whether on a break or not.
Within the specific clinical setting
where the subject participants were
tested, there was a telephone exten-sion that could have been used to call
the charge nurse in the break room to
return to the patient care unit right
away. There was also an emergency
alarm button that could have been
pushed, which would have immedi-ately notified everyone in all of that
clinic’s locations that the situation was
Nephrology Nursing Journal January-February 2014&nbsp; Vol. 41, No. 1 46
Error Recovery by Dialysis Technicians
critical. When the emergency alarm is
pressed everyone in the building
responds.
Procedural Error 2: The pa&nbsp; -tient should