29/01/19

Patient Safety Update

Patient Safety Committee Update

As previously advised, the Patient Safety Committee is aware of 3 separate instances in different dialysis units of line leaks during haemodialysis treatment. We are now setting up a working group to investigate these and any other similar incidents further. We would be grateful for reports of any incidents involving connection leaks between patient lines and machine lines during CVVH/HD or plasma exchange treatment. We have previously highlighted interim recommendations on the Renal Association website. As usual, any incident reported to RA-BRS PS should also be reported to MHRA or NRLS in the usual way. If you are interested in joining this working group please contact the group.

 

NHSI Patient Safety Alert

A NHS Improvement patient safety alert has been issued on the management of life-threatening bleeds (LTB) from AVF and AVG in patients receiving haemodialysis. The alert signposts to resources for patients, carers and colleagues. These were produced jointly by the BRS and VASBI to aid recognition and response to warning signs of LTB. Local guidance should raise awareness of these resources and incorporate the advice for detection and management of at risk patients and for management of LTB. The full alert can be found here.