Abstract
A patient died due to a mistake in the replacement of a blood purification device in November, 2011 at Kyoto University Hospital. In this article, the accident is briefly reviewed, and recurrence prevention measures presently implemented are described. The patient was a male in his fifties with decompensated liver cirrhosis undergoing chronic maintenance hemodialysis. He was emergently admitted as a brain-dead donor was found while he was waiting for a liver transplantation. Following partial brain-dead liver transplantation, continuous hemodiafiltration (CHDF) was initiated. On the 7th postoperative day, a plasma separator was mistaken for a hemofilter in the replacement of the CHDF channel, causing rapid exacerbation of the condition and death of the patient 13 hours after the replacement. Post-hoc examination revealed problems including: (1) poor management of materials that can be mixed up, (2) inadequacy of the CHDF execution system, and (3) inability to detect the cause of the rapid exacerbation of the condition until the death of the patient in holiday and night medical examinations. As a result, a 24-hour system for CHDF channel assembly by clinical engineers was established, a manual of the CHDF procedure to be shared by the entire hospital was prepared, and education of the staff in blood purification therapy was intensified.
