Unexpected cyanosis in a haemodialysis patient—did someone add hydrogen peroxide to the dialysis water? - Nicholas Newbigging, Willis Peel, Ewan Bell and Christopher Isles

Link to abstract.  NDT Plus - 2:2:158-160 - April 2009  
We wish to report the cases of four patients who became unwell during dialysis and were found to have methaemoglobinaemia following inadvertent exposure to hydrogen peroxide that had been used to decontaminate the hospital's main water tank. We believe that this is only the second such report of its kind and that patients dialyzing in renal units that still rely on mains water for dialysis remain at risk.

The Medical Directorship of Renal Dialysis Facilities under the New Medicare Conditions for Coverage: Challenges and Opportunities - Peter B. DeOreo

Link to abstract.  Blood Purification - 27:1:16-21 - January 2009  
Medical directors will find that participation in renal network quality improvement programs and initiatives will enhance their facility's QAPI program.

Improvements in Technology: A Path to Safer and More Effective Hemodialysis - Richard A. Ward, Claudio Ronco

Link to abstract.  Blood Purification - 27:1:6-10 - January 2009  
These technological innovations offer therapeutic versatility while, at the same time, reducing the burden on patient care personnel, and are likely to make an important contribution to delivering safer and more effective dialysis therapy.

VENOUS NEEDLE DISLODGEMENT: HOW TO MINIMISE THE RISKS - Jean-Pierre Van Waeleghem, Melissa Chamney, Elizabeth J. Lindley, Jitka Pancírova

Link to abstract.  Journal of Renal Care - 34:4:163-168 - December 2008  
The European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) has produced 12 practice recommendations to help reduce the risk of VND and detect blood leakage as early as possible. A poster summarising these recommendations has been created (Van Waeleghem et al. 2008).

CMS Issues Interpretive Guidance for Survey Process Under New Conditions for Coverage - Ralph Levy

Link to full text article.  Dialysis & Transplantation - 37:12:507-513 - December 2008  
As were the CfCs, the Guidance is organized into three general sections: patient safety, patient care, and administrative provisions. In each of these areas, CMS instructed surveyors to observe facility practices, review facility documentation, and interview patients, staff, medical directors, and others involved in the delivery of care to determine compliance with the CfCs.

Chronic Kidney Disease Adversely Influences Patient Safety - Stephen L. Seliger, Min Zhan, Van Doren Hsu, Lori D. Walker, and Jeffrey C. Fink

Link to abstract.  Journal of the American Society of Nephrology - 19:12:2414-2419 - December 2008  
In conclusion, hospitalized patients with CKD are at increased risk for adverse safety events, measured by established PSI. Further investigation is needed to develop and test interventions to reduce this risk.