02/12/19

Kidney patient safety committee (KPSC) updates

NxStage Product Safety Notice

NxStage Medical has issued a product safety notice to alert chronic dialysis facilities and home haemodialysis users of a potential patient health risk while performing chronic haemodialysis treatments in the home setting with the NxStage System One (inclusive of NxStage System one S).

A forum thread has been started on the Association of Renal Technologists website. Please encourage your technical staff to contribute to the discussion.

Citrate line locks

A recent review of patient safety incidents reported to the NRLS again highlighted the risk of injecting Sodium Citrate line locks into patients. The report indicates that ~50% of this is occurring in UK renal units. The other concern is a discrepancy in the strength of citrate line lock being prescribed and administered namely 30% and 46.7% (4% is recommended by the European Best Practice Guidelines). The KPSC intends to investigate this further. In the meantime we recommend revising your central venous catheter protocols and patient information, to raise patients’ awareness and encourage them to speak up when being cared for by non-renal staff who may not know their lines are locked.

Citrate locks tend not to be on the patients’ list of usual medication as given post dialysis.

Using clinical apps

The RCP patient safety committee has raised some concerns over the use of clinical apps. There are many apps available, but validation of them is unclear. Here is some information on evaluating apps:
RCP apps guidance factsheet
BMC medicine article
Clinical Medicine article

The MHRA has provided the following guidance:

Possible blood leaks on haemodialysis in patients with dialysis lines – current practice

The kidney patient safety committee has received correspondence from several renal units highlighting concern regarding the potential risk of blood leaks on haemodialysis in patients dialysing via dialysis lines.

A working group has been set up to examine these potential risks further.

As part of this work we would be grateful if you could take 5 -10 minutes to answer the following survey. The aim is to gather information on current practice, AIs or SUIs and any action plans related to possible blood leaks on haemodialysis in patients with dialysis lines.
Thank you in advance for your help.

Respond to the survey

New Patient Information

Removing your Temporary Haemodialysis Catheter ( Vascath) is now available.