How safe is renal replacement therapy? A national study of mortality and adverse events contributing to the death of renal replacement therapy recipients

Nephrology Dialysis Transplantation

Volumn 29, Issue 3, 2014, Pages 681-687

  Bray, Benjamin D ^a   Boyd, Jennifer ^b   Daly, Conal ^c   Doyle, Arthur ^d   Donaldson, Ken ^e   Fox, Jonathan G ^c   Innes, Andrew ^f   Khan, Izhar ^g   MacKinnon, Bruce ^c   Peel, Robert K ^h   Shilliday, Ilona ⁱ   Simpson, Keith ^c   Stewart, Graham A ^j   Traynor, Jamie P ⁱ   Metcalfe, Wendy ^k  

^a KING'S COLLEGE LONDON   (United Kingdom)

^b Information Services Division Scotland   (United Kingdom)

^c Glasgow Renal and Transplant Unit   (United Kingdom)

^d QUEEN MARGARET HOSPITAL   (United Kingdom)

^e DUMFRIES AND GALLOWAY ROYAL INFIRMARY   (United Kingdom)

^f CROSSHOUSE HOSPITAL   (United Kingdom)

^g ABERDEEN ROYAL INFIRMARY   (United Kingdom)

^h RAIGMORE HOSPITAL   (United Kingdom)

ⁱ MONKLANDS HOSPITAL   (United Kingdom)

^j NINEWELLS HOSPITAL   (United Kingdom)

^k ROYAL INFIRMARY OF EDINBURGH   (United Kingdom)

more..

Author keywords

Dialysis; Mortality; RRT; Safety; Transplantation

Indexed keywords

ADULT; ARTICLE; CARDIOVASCULAR DISEASE; FEMALE; HEMODIALYSIS; HOSPITAL PATIENT; HUMAN; HYPERKALEMIA; INCIDENCE; INFECTION; KIDNEY FAILURE; MAJOR CLINICAL STUDY; MALE; MORBIDITY; MORTALITY; OUTPATIENT; PATIENT SAFETY; PRESCRIPTION; PRIORITY JOURNAL; RENAL REPLACEMENT THERAPY; RETROSPECTIVE STUDY; STRUCTURED QUESTIONNAIRE; TREATMENT DURATION; UNITED KINGDOM; VASCULAR ACCESS; ADVERSE EFFECTS; AGED; KIDNEY FAILURE, CHRONIC; MIDDLE AGED; RISK FACTOR; SURVIVAL RATE; VERY ELDERLY;

ADULT; AGED; AGED, 80 AND OVER; FEMALE; HUMANS; INCIDENCE; KIDNEY FAILURE, CHRONIC; MALE; MIDDLE AGED; RENAL DIALYSIS; RENAL REPLACEMENT THERAPY; RETROSPECTIVE STUDIES; RISK FACTORS; SURVIVAL RATE;

EID: 84895764427     PISSN: 09310509     EISSN: 14602385     Source Type: Journal    
DOI: 10.1093/ndt/gft197     Document Type: Article

References (35)

1. Atlas of CKD and ESRD. U S Renal Data System, USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2012
2. Blix HS, Viktil KK, Moger TA et al. Use of renal risk drugs in hospitalized patients with impaired renal function - an underestimated problem? Nephrol Dial Transplant 2006; 21: 3164-3171
3. Kiaii M, Djurdjev O, Farah Met al. Use of electron beam sterilized haemodialysis membranes and risk of thrombocytopenia. JAMA 2011; 306: 1679-1687
4. Short AI, Winney RJ, Robson JS. Reversible microcytic hypochromic anaemia in dialysis patients due to aluminium intoxication. Proc Eur Dial Trans Assoc 1980; 17: 226-233
5. Rossert J, Casadevall N, Uckardt KU. Anti-erythropoetin antibodies and pure red cell aplasia. J Am Soc Nephrol 2004; 15: 398-406
6. Grohskopf LA, Roth VR, Feikin DR et al. Serratia liquefacians bloodstream infections from contamination of epoitin alfa at a haemodialysis center. N Engl J Med 2001; 344: 1491-1497
7. Scottish Renal Registry Annual Report 2008. ISD Scotland, 2009
8. Scottish Renal Registry. http://www.srr.scot.nhs.uk/index.htm (5 February 2013, date last accessed)
9. Scottish Audit of Surgical Mortality. http://www.sasm.org.uk/30 October 2012, date last accessed)
10. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building a Safer Health Care System. Washington, DC: National Academy Press, 2000
11. Donaldson L. An Organization with a Memory. UK: The Stationery Office, 2000
12. Hogan H, Healey F, Neale G et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf 2012; 21: 737-745
13. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors. JAMA 2001; 286: 415-420
14. Zegers M, de Bruijne MC, Wagner C et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 2009; 18: 297-302
15. Himmelfarb J. Optimizing patient safety during haemodialysis. JAMA 2011; 306: 1707-1708
16. Grobner T. Gadolinium - a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis? Nephrol Dial Transplant 2006; 21: 1104-1108
17. Garrick R, Kliger A, Stefanchik B. Patient and facility safety in haemodialysis: opportunities and strategies to develop a culture of safety. Clin J Am Soc Nephrol 2012; 7: 680-688
18. Seliger SL, Zhan M, Hsu VD et al. Chronic kidney disease adversely influences patient safety. J Am Soc Nephrol 2008; 19: 2414-2419
19. Chapin E, Zhan M, Hsu VD et al. Adverse safety events in chronic kidney disease: the frequency of 'multiple hits'. Clin J Am Soc Nephrol 2010; 5: 95-101
20. Bray BD, Boyd J, Daly C et al. Vascular access type and risk of mortality in a national prospective cohort of haemodialysis patients. QJM 2012; 105: 1097-1103
21. Alpert MA. Sudden cardiac arrest and sudden cardiac death on dialysis: epidemiology, evaluation, treatment and prevention. Haemodial Int 2011; 15: S22-S29
22. Einhorn LM, Zhan M, Hsu VD et al. The frequency of hyperkalaemia and its significance in chronic kidney disease. Arch Intern Med 2009; 169: 1156-1162
23. Renal Association. Treatment of Acute Hyperkalaemia in Adults. http://www.renal.org/Clinical/GuidelinesSection/Treatment-of-Acute- Hyperkalaemia-in-Adults.aspx (21 March 2013, date last accessed)
24. Harel Z, Wald R, Liu JL et al. Lapses in safety in end-stage renal disease patients admitted to surgical services. Haemodial Int 2012; 16: 286-293
25. Hug BL, Witkwoski DJ, Sox CM et al. Occurrence of adverse, often preventable, events in community hospitals involving nephrotoxic drugs or those excreted by the kidney. Kidney Int 2009; 76: 1123-1125
26. Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995; 274: 29-34
27. Pronovost PP, Baugher Hobson D, Earsing K et al. A practical tool to reduce medication errors during patient transfer from an intensive care unit. J Clin Outcomes Manage 2004; 11: 26-33
28. St Peter WL. Improving medication safety in chronic kidney disease patients on dialysis through medication reconciliation. Adv Chronic Kidney Dis 2010; 17: 413-419
29. Sari AB, Sheldon TA, Cracknell A et al. Extent, nature and consequences of adverse events: results of a retrospective case note review in a large NHS hospital. Qual Saf Health Care 2007; 16: 434-439
30. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int 2000; 58: 1758-1764
31. Marr KA. Staphylococcus aureus bacteremia in patients undergoing hemodialysis. Semin Dial 2000; 13: 23-29
32. Pesanti EL. Immunologic defects and vaccination in patients with chronic renal failure. Infect Dis Clin North Am 2001; 15: 813-832
33. Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med 2006; 355: 2725-2732
34. Von Plessen C, Kodal AM, Anhoj J. Experiences with global trigger tool reviews in five Danish hospitals: an implementation study. BMJ Open 2012; 2: e001324
35. Lilford R, Pronovost P. Using hospital mortality rates to judge hospital performance: a bad idea that just won't go away. BMJ 2010; 340: c2016