Accidents in Dialysis Units Despite Preventive Actions

1. Falls

Falls remain one of the most common adverse events in dialysis facilities. Causes include post-dialysis hypotension, dizziness, weakness, difficulty transferring, and tripping within the unit. About 40% of the time staff cannot identify the exact cause. Preventive actions like fall-risk screening, reducing polypharmacy, gait programs, and minimizing intradialytic hypotension lower rates, but do not stop all falls.

Reference: PMC4596525

2. Medication and dialysate errors

Medication omission is the most frequently reported error. Other events include wrong heparin dosing, incorrect dialysate concentrate, and missed medications during care transitions. Surveys show nearly two-thirds of ESRD professionals witnessed at least one incorrect dialyzing solution setup in a 3-month period. Standardized protocols and double-checks reduce frequency, yet errors still occur roughly once per 733 treatments.

Reference: PMC4596525

3. Infections and microbiological/endotoxin contamination

Hemodialysis patients are immunocompromised and exposed to 120–200 L of water per session. Biofilm in water treatment systems, RO membranes, and machine hydraulics can release bacteria and endotoxin. Studies show 9–35% of water samples and 11–19% of dialysate samples exceed AAMI limits. Outbreaks of Gram-negative bloodstream infections and pyrogenic reactions have been documented globally from 1973–2021.

79.2% of posttreatment water samples were positive for Acanthamoeba contamination. Monthly LAL testing is only a snapshot and can miss intermittent biofilm shedding.

Reference: PMC11857269

4. Intradialytic hypotension and cardiovascular events

Sudden blood pressure drops during treatment increase fall risk and can trigger cardiac events. Cooling dialysate, adjusting ultrafiltration rates, and longer/more frequent sessions help prevent IDH. However, patient factors like age, diabetes, cardiac disease, and vascular instability mean it cannot be fully eliminated. Cardiovascular disease remains the main cause of death in HD patients, with chronic inflammatory states linked to endotoxin exposure contributing to complications.

Reference: PMID 42020017

Why these persist despite prevention

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