IDENTIFICATION AND ANALYSIS OF ROOT CAUSES OF ADVERSE EVENTS IN HAEMODIALYSIS UNITS: A QUALITY IMPROVEMENT PERSPECTIVE AT RURAL TERTIARY CARE TEACHING HOSPITAL

Author

Mr. Mantode John Raphael , Dr. Yashwant M. Palghadmal , Dr. Kajal V. Darandale


Abstract

 Background

Haemodialysis is a life-sustaining treatment for patients with chronic kidney disease and end-stage renal disease. However, the procedure involves extracorporeal circulation, vascular access, dialysis machines, fluid removal, anticoagulation, medication administration and continuous patient monitoring. These interacting clinical, technical and organizational components create multiple opportunities for adverse events. Root Cause Analysis (RCA) provides a structured approach for identifying underlying system-level contributors to adverse events and developing corrective and preventive interventions.

Aim

To identify and analyse the root causes of adverse events occurring in a haemodialysis unit and examine their implications for quality improvement and patient safety in a rural tertiary care teaching hospital.

Methodology

A quantitative, descriptive and analytical hospital-based study was conducted in the haemodialysis unit of a selected rural tertiary care teaching hospital in Ahilyanagar District, Maharashtra. The study included 100 haemodialysis patients/sessions as reported in the dissertation. Data were obtained through retrospective review of patient and dialysis records and adverse-event reports, together with prospective observation. Demographic and clinical information was collected using a structured data sheet. Root Cause Analysis was performed using Fishbone Diagram and 5 Whys techniques. Descriptive statistics and appropriate inferential statistical tests were applied using Excel and R software.

Results

The mean age of participants was 48±16 years and the study population was predominantly male. Secondary education and self-employment were the most frequently reported educational and occupational categories. Among the adverse events reported, manpower-related events constituted 48.5% (n=16), access-related problems 21.2% (n=7), hypotension 18.2% (n=6), bleeding 3.0% (n=1), and other events 9.1% (n=3). RCA identified manpower as the largest individual root-cause category, accounting for 44.4% (n=16), followed by machine-related causes at 13.9% (n=5) and management-related causes at 8.3% (n=3). Several events involved combinations of root-cause categories, demonstrating that adverse events frequently arose from interacting system factors. A statistically significant association was reported between haemoglobin group and occurrence of adverse events (p=0.035).

Conclusion

The study indicates that adverse events in haemodialysis are influenced by interconnected manpower, machine, method, material and management factors. RCA can provide a practical framework for converting individual adverse-event reports into system-level quality-improvement opportunities. In rural tertiary care settings, routine incident reporting, staff training, protocol adherence, equipment monitoring, clinical surveillance and periodic RCA meetings may strengthen patient safety.



Keywords

Haemodialysis; Adverse Events; Root Cause Analysis; Fishbone Diagram; 5 Whys; Patient Safety; Quality Improvement; Rural Hospital; Dialysis Safety.



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References


  1. Haroon SWP, et al. Risk assessment of failure during transitioning from in-centre to home haemodialysis. BMC Nephrol. 2022;23:406.
  2. Balson L, Stevenson T, Baharani J. Using root cause analysis as a tool to reduce central venous catheters in haemodialysis patients. J Vasc Access. 2022;25(1):239-243.
  3. Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet. 2018 May 1.
  4. Kliger AS, et al. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2014;9(12):2113-2119.
  5. Holley JL. A descriptive report of errors and adverse events in chronic haemodialysis units. Nephrol News Issues. 2006;20(12):57-63.
  6. Rocha RPF, et al. Occurrence of adverse events in public haemodialysis units. Enferm UERJ. 2019;27:e36712.
  7. Nguyen DB, et al. Haemodialysis-associated infections. Clin Kidney J. 2018;11(1):5-13.
  8. Walton E, et al. Haemodialysis bleeding events and deaths: an 18-year retrospective analysis. J Patient Saf. 2022;18(3):e620-e625.
  9. Albreiki S, et al. A systematic literature review of safety culture in haemodialysis settings. Int J Healthc Manag. 2023;16(2):130-139.
  10. Kumah A, et al. Cause-and-effect (Fishbone) diagram: a tool for root cause analysis. J Patient Saf Qual Improv. 2024;12(2):45-51.
  11. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770.
  12. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
  13. Chertow GM, Levin NW, Beck GJ, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24):2287-2300.
  14. Agarwal R. How can we prevent intradialytic hypotension? Curr Opin Nephrol Hypertens. 2012;21(6):593-599.
  15. Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis and cardiovascular morbidity and mortality. Kidney Int. 2011;79(2):250-257.
  16. Lok CE, Huber TS, Lee T, et al. KDOQI clinical practice guideline for vascular access. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164.
  17. Daugirdas JT, Blake PG, Ing TS. Handbook of Dialysis. 5th ed. Philadelphia: Wolters Kluwer; 2015.
  18. Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG. Vascular access and all-cause mortality: a propensity score analysis. J Am Soc Nephrol. 2004;15(2):477-486.
  19. Mactier R, Hoenich N, Breen C. Renal Association Clinical Practice Guideline on haemodialysis. Nephron Clin Pract. 2011;118(Suppl 1):c241-c286.
  20. Weinger MB, Pantiskas C, Wiklund ME, Carstensen P. Human factors and patient safety in anesthesia and dialysis care. Qual Saf Health Care. 1998;7(Suppl):i47-i52.
  21. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
  22. World Health Organization. Patient Safety: Making Health Care Safer. Geneva: WHO; 2017.
  23. Percarpio KB, Watts BV, Weeks WB. The effectiveness of root cause analysis: what does the literature tell us? Jt Comm J Qual Patient Saf. 2008;34(7):391-398.
  24. Vincent C. Patient Safety. 2nd ed. Oxford: Wiley-Blackwell; 2010.
  25. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
  26. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2021;77(4 Suppl 1):A7-A8.
  27. Bikbov B, Purcell CA, Levey AS, et al. Global, regional, and national burden of chronic kidney disease. Lancet. 2020;395(10225):709-733.
  28. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Recomm Rep. 2001;50(RR-5):1-43.
  29. Finkelstein FO, Story K, Firanek C, et al. Health-related quality of life and haemodialysis patients. Kidney Int Suppl. 2009;(114):S117-S121.
  30. Tschannen D, Aebersold M, McLaughlin E, Bowen J, Fairchild J. Use of virtual simulations for improving patient safety in dialysis settings. Clin Simul Nurs. 2012;8(8):e419-e425.

 

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