The key concept of patient safety in acute blood purification

Abstract

Every medical institution is under an obligation to keep the patients safe. However, blood purification systems carry a risk of error both in critical care and chronic maintenance hemodialysis. Patients with an unstable life-threatening condition supported by many medical devices are often managed by a multidisciplinary team of medical professionals. Inadequate communication among these professionals threatens patient safety in case of intensive acute blood purification. The Japan Council for Quality Health Care (JQ) has been conducting the Project to Collect Medical Near-miss/Adverse Event Information. Every process of blood purification could involve adverse events such as extravascular leakage on the central vein cannulation for vascular access, using a different filter, setting a wrong filtration rate, accidental removal of the tube or air entering into the blood vessel, and anticoagulant related errors and accidents. Therefore, patients’ informed consent needs to be secured after explaining these risks. Technological advancements have helped develop failsafe and foolproof systems. However, “To Err is Human,” which means that we cannot avoid near-misses and errors. Consequently, to operate highly complicated and life-threatening medical systems, we should strive to create a highly reliable organization that has an “informed culture.” This includes reporting the awareness or experience of errors, justice, flexibility to adapt to sudden and unexpected situations, and learning from near misses and errors.