Kidney Patient Safety 2007-2025

The phrase “Primum non nocere” (“first, do no harm”) is attributed to the English Physician Thomas Sydenham (1624-89). In the 75 years since the institution of the Renal Association, the developments in the treatment of kidney diseases, dialysis and transplantation have saved countless lives. However, our treatments, our equipment and our clinical care can sometimes put our patients at risk and incur actual harm, through what we erroneously do or omit to do.

Our Kidney Patient Safety initiatives started in 2007, when Paul Rylance was asked to represent the Renal Association on a National Patient Safety Agency (NPSA) working party that published a report "Safer care for the acutely ill patient: learning from serious incidents". From this developed a collaboration with the NPSA, not only to learn and take actions from serious incidents but also to identify risks to patients to prevent incidents occurring. Hence, the Kidney Patient Safety Committee (KPSC) was developed. The NPSA was able to identify recurring incidents from their National Learning and Reporting System (NRLS) database, and the KPSC was able to give advice to formulate alerts to be circulated to renal units. Similarly, renal units could also report incidents, risks and concerns to the KPSC, and the NRLS could be searched for similar events.

Two notable themes have emerged:

  • Incidents related to dialysis equipment, either from failure of the device or from user error. Through these events, our relationship with the MHRA (Medicines and Healthcare products Regulatory Agency) developed.
  • Risk and harm to kidney patients through vascular access, both fistulas and dialysis catheters. The expertise of the BRS Vascular Access Special Interest Group (now the ANN UK Vascular Access Community of Practice) in collaboration with VASBI (Vascular Access Society of Britain & Ireland) has been valuable in ensuring the sharing of best practice.

From the start, the KPSC was a multi-professional group initially with dialysis nurses and technologists contributing, but quickly recruiting representation from renal pharmacists, psychologists, patients, renal industries and the MHRA.

Serious Incidents identified by the MHRA, Coroners, Royal College of Physicians and the Health Services Safety Investigations Body (HSSIB), have been brought to the KPSC for discussion and advice, and we have contributed to investigations and reports.

Outputs from the KPSC include

  • Collaborating with the MHRA to produce a summary of known safety issues with dialysis and continuous renal replacement therapy (CRRT), describing how to minimise or prevent serious injury
  • Recommendations for safer haemodialysis care in vascular access
  • Managing behaviours that present challenges in a dialysis setting

We are encouraged that our work has been recognised by the Royal College of Physicians' Patient Safety Committee as being ‘ahead of the game’ in developing patient safety strategies. This is due to the leadership of our current Co-Chairs Karen Jenkins and Katy Jones, together with multi-professional and patient contributions of the KPSC, and our kidney care colleagues across the UK.

“An ounce of prevention is better than a pound of cure”, according to either Benjamin Franklin (1736) or the Dutch scholar Desiderius Erasmus (c1500). As the KPSC approaches 20 years of activity, where should we go in the future to ensure the safety of our kidney patients?

  1. We need to encourage patient safety awareness as a core element of our philosophy of clinical kidney care.
  2. All kidney units should consider having “safety champions” who have the defined role to educate, encourage, enthuse and evaluate patient safety wherever kidney patients are cared for in hospitals and the community. Champions, may be staff, patients or carers.  
  3. We need to look more to identifying risks and putting in measures to avoid harm.
  4. Healthcare workers should report through Datix, or other reporting systems, not just serious incidents, but also near misses, to allow learning and drive change.
  5. We need to work with NHS England to determine how we can use the new incident database “Learn From Patient Safety Events” (LFPSE) to highlight risks for kidney patient safety.
  6. Known risks continue to cause incidents. We need to revisit risks we have already responded to and ensure sharing and embedding of learning in day-to-day practice.
  7. Failure of supply chains for devices, disposables and pharmaceuticals requires us to work with industries and governments to ensure the safety of our kidney patients is not compromised by sudden lack of availability.

 

Professor Paul Rylance
October 2025