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Patient Safety in End-Stage Renal Disease: How Do We Create a Safe Environment?

  • Author Footnotes
    1 Alan S. Kliger, MD, is the medical director of New Haven CAPD, serves as Chair, End-Stage Renal Disease (ESRD) Network 1, and Chair, Quality Improvement Committee, Forum of ESRD Networks. He also serves as Chair of the Patient Quality Care Committee of the Renal Physicians Association. The views expressed in this paper do not reflect the views of ESRD Network 1, the Forum of ESRD Networks, or the Renal Physicians Association
    Alan S. Kliger
    Correspondence
    Address correspondence to Alan S. Kliger, MD, 136 Sherman Ave, New Haven, CT 06511
    Footnotes
    1 Alan S. Kliger, MD, is the medical director of New Haven CAPD, serves as Chair, End-Stage Renal Disease (ESRD) Network 1, and Chair, Quality Improvement Committee, Forum of ESRD Networks. He also serves as Chair of the Patient Quality Care Committee of the Renal Physicians Association. The views expressed in this paper do not reflect the views of ESRD Network 1, the Forum of ESRD Networks, or the Renal Physicians Association
    Affiliations
    From Yale University School of Medicine, Renal Research Institute, New Haven, CT; and The MEDSTAT Group, Washington, DC
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  • Author Footnotes
    2 Louis H. Diamond, MB, ChB, FRCP is Vice President and Medical Director of The MEDSTAT Group. He currently serves as Chair, Application and Learning Program, National Patient Safety Foundation (NPSF); Chair, Medical Informatics Forum, American College of Medical Quality (ACMQ); President, End-Stage Renal Disease (ESRD) Network 5; Immediate Past President, Forum of ESRD Networks, and represents RPA as Delegate, American Medical Association (AMA) House of Delegates. The views expressed in this paper do not reflect the views of The MEDSTAT Group, NPSF, ACMQ, RPA, or ESRD Networks
    Louis H. Diamond
    Footnotes
    2 Louis H. Diamond, MB, ChB, FRCP is Vice President and Medical Director of The MEDSTAT Group. He currently serves as Chair, Application and Learning Program, National Patient Safety Foundation (NPSF); Chair, Medical Informatics Forum, American College of Medical Quality (ACMQ); President, End-Stage Renal Disease (ESRD) Network 5; Immediate Past President, Forum of ESRD Networks, and represents RPA as Delegate, American Medical Association (AMA) House of Delegates. The views expressed in this paper do not reflect the views of The MEDSTAT Group, NPSF, ACMQ, RPA, or ESRD Networks
    Affiliations
    From Yale University School of Medicine, Renal Research Institute, New Haven, CT; and The MEDSTAT Group, Washington, DC
    Search for articles by this author
  • Author Footnotes
    1 Alan S. Kliger, MD, is the medical director of New Haven CAPD, serves as Chair, End-Stage Renal Disease (ESRD) Network 1, and Chair, Quality Improvement Committee, Forum of ESRD Networks. He also serves as Chair of the Patient Quality Care Committee of the Renal Physicians Association. The views expressed in this paper do not reflect the views of ESRD Network 1, the Forum of ESRD Networks, or the Renal Physicians Association
    2 Louis H. Diamond, MB, ChB, FRCP is Vice President and Medical Director of The MEDSTAT Group. He currently serves as Chair, Application and Learning Program, National Patient Safety Foundation (NPSF); Chair, Medical Informatics Forum, American College of Medical Quality (ACMQ); President, End-Stage Renal Disease (ESRD) Network 5; Immediate Past President, Forum of ESRD Networks, and represents RPA as Delegate, American Medical Association (AMA) House of Delegates. The views expressed in this paper do not reflect the views of The MEDSTAT Group, NPSF, ACMQ, RPA, or ESRD Networks
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      The Institute of Medicine estimated that 44,000 to 98,000 hospitalized patients die annually as a direct result of preventable medical errors. Errors occur because competent practitioners are human, and the systems we design are imperfect. Improving patient safety requires acknowledging medical errors, encouraging the reporting of errors, and improving systems to reduce the likelihood of future errors. Several challenges must be addressed to accomplish this goal. The definition of medical errors must be widely agreed on and accepted. Adverse outcomes are often the result of multiple systems failures. Therefore systems analysis, not blaming an individual, should be the focus of error reduction. A “culture of safety” should be created, which encourages reporting errors and “near-misses.” An effective reporting system has 2 components, one for public accountability for errors that result in serious injury and another for confidential reporting of mistakes that have the potential for serious injury. Regulatory protection from discovery must be established for voluntary error and near-miss reporting systems. In the nephrology community, novel uses of technology should be sought to prevent errors, human factors leading to errors should be identified and anticipated, and patterns of interaction at the machine-human interface should be studied. Progress in improving patient safety has occurred in some areas, such as pharmacy services. Such known and tested patient safety practices should be deployed in dialysis facilities. Success in improving patient safety will require leadership, collaborative efforts among the many stakeholders in the ESRD program, and adequate allocation of resources.

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