Patient Safety
The Kidney Patient Safety Committee provides leadership and professional advice on safety issues affecting people receiving kidney care. It identifies and considers kidney-specific incidents and risks, promotes shared learning and works with relevant organisations to support safer practice across UK kidney services.
The committee brings together healthcare professionals, patient representatives, regulators, suppliers and other partners with relevant expertise. It meets regularly to review reported concerns, emerging risks, safety alerts and issues affecting medicines, equipment and the delivery of kidney care.
Outputs
Shared Learning & Guidance
A patient on warfarin and aspirin started haemodialysis via a basilic vein transposition fistula. On the first dialysis session, there was a fistula “blow” and it was rested. Two days later, at the end of the second dialysis session, the venous needle was noted to be “bypassing” (there was evidence of bleeding around the needle at the insertion site). The needle was removed, and pressure applied. However, the bleeding did not stop and the patient’s condition deteriorated. The upper arm and chest wall were swollen with haematoma. The needle insertion site was sutured by the vascular surgeon with no further external bleeding. INR >11 and vitamin K and clotting factors given. Sadly the patient deteriorated and died.
Contributing factors:
- New fistula
- Deep fistula
- Unrecognised internal bleeding
- Very high INR
Learning points:
- Teams must be extra vigilant when cannulating a new fistula and undertake regular observations
- Blood loss can be underestimated
- Patients taking anticoagulants are at increased risk of fistula bleeds
- Prompt recognition of major fistula bleeding and initiation of local Major Haemorrhage Protocol is essential
The UKKA KPSC have produced a summary of known safety issues with dialysis and continuous renal replacement therapy (CRRT), describing what to do to minimise or prevent serious injury – produced in collaboration with the Medicines and Healthcare products Regulatory Agency.
Produced with the Association of Nephrology Nurses UK and the Welsh Renal Clinical Network, this document aims to provide standardised and patient-centred guidance on the management of challenging behaviour in dialysis settings.
Managing Behaviours that Present Challenges in a Dialysis Setting
Currently under review
All patients with haemodialysis vascular access are at risk of venous or arterial needle/line disconnection or dislodgement which is a life-threatening incident.
The UK Kidney Association Kidney Patient Safety Committee, in collaboration with ANN UK Vascular Access Community of Practice, VASBI (Vascular Access Society of Britain and Ireland) and Industry partners, have produced two new resources:
STOP guidance (Safety, Taping, Observation, Pressure monitoring) to enable patients/carers and health care professionals to maintain safety and reduce the risk of needle, line or catheter dislodgement/disconnection.
MARC poster (Mute, Assess, Reset, Confirm) to raise awareness of safe haemodialysis machine alarm handling.
Local reporting systems
All incidents that have caused, or might potentially have caused, harm to patients should always be reported via your local reporting system.
Any incident related to medicines or devices (equipment, disposables, computer equipment or software) should be reported to the MHRA using the Yellow Card reporting form via this link.
Serious incidents, particularly related to the failure of clinical practice, can also be reported directly to NHS England via internal systems.