2015 Volume 6 Issue 1 Pages 3-9
Herein, we describe the recurrence prevention measures and challenges for a serious medical accident caused by a mix-up in blood purification columns at Kyoto University Hospital in November 2011. Investigation committees have identified several problems to be solved, and we have implemented recurrence prevention measures including (1) the establishment of continuous hemodiafiltration (CHDF) circuit assembly by a clinical engineer (CE) all day; (2) the separation of CHDF order into materials and configurations; (3) device management; (4) the integrative renewal of operation procedures on CHDF and plasma exchange and the unification of operation procedures among intensive care units; (5) the provision of continuous education for nurses and the authorization of a certified blood purification nurse; and (6) the reinforcement of the care system between the blood purification center and other departments. In order to prevent another fatal error through education, we have offered several courses to enable both duty CEs and nurses to enhance their blood purification skills. We have also authorized a certified blood purification nurse who has passed an examination. Despite these measures, we continue to face problems that cannot be solved easily. For example, the shape of blood purification columns, such as blood ports and dialysate ports, is standardized and, as such, it is impossible to prevent the error from recurring. The setting display also differs for each CHDF device, leading to improper operation and accidents. The cooperation of the relevant manufacturers is essential to the further improvement of recurrence prevention measures and proposals.
