Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective.

BACKGROUND

There has been resurgent interest in home hemodialysis (HD) in recent years because of the reported benefits and its excellent safety record. However, the potential for adverse events, including potentially catastrophic ones, exists when patients are performing HD in their homes without supervision. There is a lack of literature on this important topic.

STUDY DESIGN

Quality improvement report.

SETTING & PARTICIPANTS: We present the experience of 2 adult home HD programs in Canada from 2001 to 2012, including a total of 190 patients and approximately 500 patient-years of treatments.

QUALITY IMPROVEMENT PLAN

We retrospectively reviewed all life-threatening adverse events occurring in our programs and re-examined our approach to patient training, retraining, and safety monitoring.

RESULTS

We report 1 death and 6 potentially fatal adverse events, yielding a crude rate of 0.060 events/1,000 dialysis treatments. Six of 7 events involved significant blood loss (including 1 exsanguination); 5 of 7 events involved human error with lapses in protocol adherence. Because such events are rare, evaluation of specific intervention strategies will require much longer follow-up.

LIMITATIONS

Retrospective identification of cases. A specific quality improvement initiative was not undertaken.

CONCLUSIONS

Life-threatening adverse events in home HD are uncommon; however, when one does occur, this should prompt review of home HD-related policies and procedures to make this therapy even safer.