Skip to main content
Erschienen in: BMC Nephrology 1/2022

Open Access 01.12.2022 | Research

Risk assessment of failure during transitioning from in-centre to home haemodialysis

verfasst von: Sabrina-Wong-Peixin Haroon, Titus-Wai-Leong Lau, Gan Liang Tan, Eugene-Hern Choon Liu, Soh Heng Hui, Siao Luan Lim, Diana Santos, Robyn Hodgson, Lindsay Taylor, Jia Neng Tan, Andrew Davenport, FH HHD

Erschienen in: BMC Nephrology | Ausgabe 1/2022

Abstract

Background

Introducing a de-novo home haemodialysis (HHD) program often raises safety concerns as errors could potentially lead to serious adverse events. Despite the complexity of performing haemodialysis at home without the supervision of healthcare staff, HHD has a good safety record. We aim to pre-emptively identify and reduce the risks to our new HHD program by risk assessment and using failure mode and effects analysis (FMEA) to identify potential defects in the design and planning of HHD.

Methods

We performed a general risk assessment of failure during transitioning from in-centre to HHD with a failure mode and effects analysis focused on the highest areas of failure. We collaborated with key team members from a well-established HHD program and one HHD patient. Risk assessment was conducted separately and then through video conference meetings for joint deliberation. We listed all key processes, sub-processes, step and then identified failure mode by scoring based on risk priority numbers. Solutions were then designed to eliminate and mitigate risk.

Results

Transitioning to HHD was found to have the highest risk of failure with 3 main processes and 34 steps. We identified a total of 59 areas with potential failures. The median and mean risk priority number (RPN) scores from failure mode effect analysis were 5 and 38, with the highest RPN related to vascular access at 256. As many failure modes with high RPN scores were related to vascular access, we focussed on FMEA by identifying the risk mitigation strategies and possible solutions in all 9 areas in access-related medical emergencies in a bundled- approach. We discussed, the risk reduction areas of setting up HHD and how to address incidents that occurred and those not preventable.

Conclusions

We developed a safety framework for a de-novo HHD program by performing FMEA in high-risk areas. The involvement of two teams with different clinical experience for HHD allowed us to successfully pre-emptively identify risks and develop solutions.
Hinweise

Supplementary Information

The online version contains supplementary material available at https://​doi.​org/​10.​1186/​s12882-022-03039-4.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abkürzungen
HHD
Home haemodialysis
ICHD
In-centre (ICHD)
ESKF
End stage kidney failure
HD
Haemodialysis
FMEA
Failure mode effects analysis
NUH
National University Hospital Singapore
RFH
Royal Free Hospital
RPN
Risk priority number
RO
Reverse osmosis
MSSA
Methicillin-sensitive staphylococcus aureus
MRSA
Methicillin-resistant staphylococcus aureus
KDOQI
Kidney Disease Outcomes Quality Initiative
HAH
Hospital at home

Background

The past decade has seen a growing literature reporting superior outcomes for home haemodialysis (HHD) patients compared to patients dialysing in-centre (ICHD) [1, 2]. The benefits of HHD extend beyond flexibility in scheduling, reduced travel time, and improved quality of life when receiving dialysis treatment in a familiar home environment [3, 4]. Recently published studies of HHD have even reported comparable survival to deceased donor renal transplant patients [5, 6]. Many renal programmes are now advocating HHD, in addition to peritoneal dialysis (PD), as the preferred modality choice for chronic maintenance dialysis patients.
Although HHD is not a new modality and has a good safety record in established programmes [7, 8], Singapore is only just initiating a pilot programme. Our programme will offer suitable local end stage kidney failure (ESKF) patients who are already receiving haemodialysis (HD) or have chosen HD as their long-term option to be treated at home. The adoption of home dialysis has been slow, in part because Singapore is geographically small and well connected with one of the world’s leading public transportation systems. Older patients have also been reluctant to accept that dialysis treatments can be performed safely at home. Fortunately, with wider exposure and better health literacy over recent years, there are now an increasing number of patients keen to participate in HHD as a long-term dialysis modality [911].
The fundamentals of HD are essentially the same, whether ICHD or HHD. In Singapore 80% of patients with chronic kidney disease treated by dialysis attend ICHD [12]. For our pilot trial of HHD, we excluded patients using tunnelled catheters for vascular access, given the higher risk of adverse incidents [13]. We decided to make a caregiver a requirement for the initial patients starting HHD to improve patient confidence while starting this new modality option to patients used to ICHD. The prerequisite requirement of a mandatory caregiver is more restrictive in allowing access to HHD. Although previously published reports do not demonstrate that the presence of a care giver translates into reducing the risk of adverse events [13] but a caregiver was chosen to allay the anxieties of patients and stakeholders.
For HHD, the major goals are to prepare the staff both as educators and trainers, the patient and the home ready for dialysis. As we are starting and adopting a new modality that will change the landscape of chronic maintenance dialysis locally in Singapore, we strengthened our HHD risk assessment by evaluating the risk of failure in the processes of HHD using the Failure Mode Effects Analysis (FMEA) tool. FMEA has been used in many healthcare settings, including ICHD, to assess various new critical policies and procedures before implementation and also to identify areas for improvement [1417]. Our study will be the first to use FMEA to evaluate the risk of failure in HHD. We collaborated with one of the pioneers of HHD, the Royal Free Hospital in London, to further strengthen and validate our results. We aimed to review potential failures in the HHD process and identify the highest risk areas to help us develop prioritised interventions designed to prevent failures or at least minimise risks. We also defined remedial actions to mitigate the impact and consequences of any failures.

Methods

We conducted a FMEA between July 2020 to February 2021 with teams from the National University Hospital Singapore (NUH) and Royal Free Hospital (RFH) in London. The FMEA was performed independently and adjusted collaboratively. We performed our FMEA in the following manner:
  • Step 1: Selection of team members.
  • Step 2: Process scope identification and listing of all key processes (using process flowchart).
  • Step 3: Identification of failure mode.
  • Step 4: Scoring based on risk priority numbers.
  • Step 5: Designing solutions to eliminate and mitigate risk.
Ethics approval for the study was not required by The National Healthcare Group Institutional Review Board in Singapore as failure mode effect analysis does not meet the definition of human-subject research. All methods were performed in accordance with the relevant institutional guidelines and regulations.

Step 1: team selection

We identified the key members for the FMEA process and recruited cross-functional members with diverse and in-depth knowledge of HD and HHD from both NUH and RFH. Teams from these two hospitals shared common expertise in HD but were distinct in that one is planning for the initiation of a HHD programme, whereas the other has decades of experience in HHD. Together, we provided unique perspectives of a HHD programme at different phases of maturity.

Step 2: process identification and process flowchart preparation

We reviewed the established processes involved in the HHD journey at RFH and conducted a search on the HHD processes in PubMed. Each team identified and listed all key processes and subprocesses in HHD independently, and this was subsequently collated to map the final processes and subprocesses.

Step 3: failure mode identification

We reviewed the HHD experience at the RFH and used “brainstorming” sessions and an extensive review of published literature to identify all the possible failure modes in HHD. We listed all potential failures that can occur at each step in the flowchart and found that the area with the highest risk involves the transition phase of patients from in-centre haemodialysis to home.
A list of potential failure modes during the process of transitioning to home was generated. The list was categorised, reviewed for accuracy and completeness by both the NUH and RFH teams. The possible areas of failure were identified, considering contributing factors and potential consequences.

Step 4: scoring based on risk priority numbers

In the areas of greatest concern, we rated each process failure for likelihood (remote to very high), severity (none to catastrophic), and detectability (almost certain to absolutely uncertain) using a consensus approach. The risk priority number (RPN) was then calculated for each potential failure mode. The RPN is the quantitative estimate of the risk associated with each failure mode (Table 1) [18]. FMEA teams assigned an RPN to each failure mode based on three factors: (1) the likelihood of occurrence (L), (2) the degree of severity if it does occur (S), and (3) the likelihood of detecting the occurrence (D). The RPN was calculated using the formula: L x S x D, where high numbers indicate a high priority for intervention and action [19, 20]. The scores were determined based on consensus, following discussions between NUH and RFH team members. A failure mode with an RPN of 100 or greater was considered a high priority and was further investigated and documented in the FMEA worksheet (Table 2) [21, 22].
Table 1
Risk priority definition and rating scales [18]
Risk priority number
Definition
Rating scales
Likelihood
The perceived chance of the failure happening within a defined period
Rating of 1–10: ‘failure is unlikely’ to ‘very likely or inevitable’
Severity
How severe the outcome is to the patient should failure occur
Rating of 1–10: ‘no severity at all’ (would not affect individual or system) to ‘moderate’ (significant effect with no injury) to ‘major injury’ to ‘death’
Detectability
Is the area of failure readily known, or is it discovered only when an adverse outcome occurs?
Rating of 1–10: ‘almost certain the process or steps will detect potential cause(s)’ to ‘absolute uncertainty that the control will not detect potential cause(s) and subsequent failure mode (s)
Table 2
Possible areas of failure during transitioning to home haemodialysis
Steps
Failure mode
1. Setting up HHD system at home
 Setting up HD Machine
Machine cannot be placed in the space at home
 Setting up water treatment system
Portable RO cannot be placed in the space at home
Connection of portable RO and machine cannot be achieved
 Setting up drainage
Violating municipal standards for discharge of dialysis effluent
Incorrect technical requirement for height of drainage hole
 Setting up and establishing power and water supply
Power socket not suitable for machine / portable RO
Power socket not sited correctly
Connector to water point incompatible
Water points not sited correctly
Inadequate water pressure to operate the portable RO
Water temperature too high or too low
 Creating storage and getting consumables ready
Lack of storage for consumables
Consumables passed shelf-life (beyond expiration date)
2. Completing test prior to starting HHD
 Checking water treatment system
Failure to achieve meet minimum safety and quality levels of dialysis water and fluid requirement
 Initiating HD machine self-test
Repeatedly fails self-test
3. Performing HHD
3a. Preparing HHD
  Starting HD Machine
Machine cannot be switched on
Machine breakdown
  Starting water treatment system
Portable reverse osmosis (RO) cannot be switched on
Portable RO breakdown
Incorrect portable RO connection
  Ensuring drainage
Inadequate water or dialysate flow
Inadequate water pressure
Blocked drainage
Flooding from cracked lines or choked drainage
  Starting power and water supply
Interruption in water supply
Interruption in power supply
  Gathering dialysis consumables
No or insufficient supply of consumables needed for treatment
Incorrect supply of consumables
Failure to supply heparin
Failure to supply disinfectant
3b. Evaluation before starting dialysis
  General evaluation
Starting dialysis when feeling unwell or have temperature > 38o C, heart rate > 110 or < 50 beats per minute, systolic blood pressure > 180 mmHg or < 100 mmHg
  Priming and connectivity of dialysis blood lines
Poor connection
Incorrect connection
Kinked blood lines
  Measuring weight
Error in weight taken
Incorrect dry weight
  Deciding and calculation of ultrafiltration
Excessive ultrafiltration
Inadequate ultrafiltration
  Taking medications before dialysis
Taking excessive antihypertensive medications
Forgot to take antihypertensive or taking lower dose
3c. Managing vascular access during dialysis treatment
  Cleaning of access site
Non-compliance to cleaning of access site
  Scab removal for those of buttonhole cannulation
Incomplete scab removal for buttonhole cannulation
  Establishing access cannulation
Unsuccessful access cannulation after three attempts
  Cannulation technique
Defective technique in cannulation access
  Securing vascular access
Poor fixation of needles to skin, traction of circuit line or movement especially during nocturnal dialysis
  Troubleshooting alarm related to vascular access
Failure to respond to arterial and venous pressure alarm
  Monitoring vascular access during dialysis
Failure to monitor vascular access during dialysis
  Vascular access needles removal
Excessive and prolonged bleeding after removal of dialysis needles
  Monitoring vascular access (general)
Failure to identify access related infection
3d. Interruption and management of machine alarms
  Reprogramming after temporary interruption
Failure to reprogram after disconnection
  Troubleshooting dialysis machine alarms
Dialysate (conductivity and temperature) alarm trigger
Air detection alarm trigger
Blood leak alarm trigger
  Calling for help
Unable to reach nursing or technical assistant for advice
  Emergency during dialysis treatment
Need for emergency evacuation
3e. Administering medications on dialysis
  Administering anticoagulation
Excessive heparin administered
  Administering new medications or using new consumables
Allergic reaction
3f. Other
  Caregiver assisting HHD
Needle-stick injury to family member or caregiver
3g. Ending dialysis
  Disposal of HD items
Improper of disposal biohazard waste
Sharps box missing

Step 5: designing solutions to eliminate, mitigate risk and risk review

For the highest area of concern, potential solutions to mitigate risks and interventions were evaluated. As risk mitigation in this area usually involved a bundle approach and so was often overlapping, we discussed all possible solutions for each failure in the area concerned. We had extensive discussions for areas with RPN scores more than 100. A risk review process is planned prospectively as the HHD program starts to refine the FMEA.

Results

The NUH team consisted of three nephrologists with one having formal training in patient safety and healthcare quality, a senior renal nurse manager, one newly trained HHD nurse, a representative from hospital clinical governance experienced in conducting regular FMEA, an administrative executive, and a non-renal physician trained in healthcare quality from another independent (non-affiliated) institution. The team from RFH consisted of a nephrologist, two nurse managers of the HHD and home therapies programs, two senior renal technologists, and two patients each with more than 10 years HHD experience. The teams had 5 meetings of approximately 2 h. FMEA was conducted separately by each team and then through video conferencing platform (ZOOM) meetings.

Flowchart of key processes in HHD

We identified all the key areas, processes and sub-processes in setting up HHD. The four major areas in HHD involve setting up the program, training of staff and patients, transferring patients from in-centre to HHD, and ongoing maintenance therapy (Fig. 1).

Failure modes and risk priority numbers

After reviewing various main areas, transitioning to HHD was found to have the highest risk of failure (Fig. 1). The FMEA on the transitioning to HHD process was independently completed by the two teams, but the final score was determined after joint deliberation. The three main processes in transitioning to HHD area are setting up the HHD system at home, completing tests before starting HHD, and performing HHD.
There was a total of 5 main steps with 13 failure modes in setting up the HHD system at home and 2 main steps with 2 failure modes in completion of the tests before starting HHD. We identified that performing HHD treatment has a total of 7 sub-processes; including (1) preparation to start HHD treatment, (2) general patient and dialysis equipment evaluation before starting dialysis, (3) managing vascular access during dialysis treatment, (4) dealing with treatment interruption and troubleshooting machine alarms, (5) administering medication during dialysis, (6) others, and (7) ending dialysis, with a total of 27 steps and 44 failure modes (Table 2). Among the sub-processes, managing vascular access during treatment has the highest failure modes (Additional file 1: Appendix 1).
Vascular access management had a total 9 steps with 9 failure modes. Failure mode effect analysis revealed scores ranging from 9 to 256 with a mean of 135 and median of 144 respectively. The highest RPNs were failure to monitor vascular access, a defective technique in cannulation access, and troubleshooting vascular access alarm with scores of 252, 256, and 180 respectively. As vascular access management and troubleshooting access alarms are overlapping and have higher RPN scores, we explored the failure modes, effect, consequences, and identified risk mitigation strategies in all 9 areas of access-related medical emergencies. In particular we emphasized 3 main areas with high RPN scores, highlighted in grey in Table 3.
Table 3
Failure modes of access related medical emergencies
Number
Steps
Failure mode
Effect/ Consequences
Likelihood
Severity
Detectability
RPN
1
Cleaning of access site
Non-compliance to cleaning of access site
Vascular access infection and septicaemia
Unable to proceed with haemodialysis using vascular access
2
6
6
72
Potential solutions for risk mitigation
1. Education and training to patient with emphasis on infection prevention measures [23, 24]
2. Performing hand hygiene before setting up table to start HHD
3. Emphasize hand washing and use of chlorohexidine swab sticks or consumables that motivate compliance
4. Regular assessment of patient performing treatment observed during home visit and during physician/home haemodialysis nursing team review at HHD unit (at least once every two months)
2
Scab removal for those of buttonhole cannulation
Incomplete scab removal
Vascular access infection and septicaemia
Unable to proceed with haemodialysis using vascular access
2
9
8
144
Potential solutions for risk mitigation
1. Preferential selection for rope ladder cannulation [25]
2. Careful consideration on suitability of buttonhole cannulation only in selected cases and strictly avoiding individuals that are recurrent methicillin-sensitive staphylococcus aureus (MSSA) methicillin-resistant staphylococcus aureus (MRSA) colonised
3. Conversion to rope ladder cannulation method for those using button-hole cannulation if MSSA or MRSA colonised
4. Specific training for buttonhole cannulation with emphasis on infection prevention measures [26]
5. Monitoring MRSA colonisation status and eradication (when needed) every three months [2730]
6. Topical mupirocin ointment to buttonhole cannulation sites [31]
7. Regular assessment of patient performing treatment observed during home visit and during physician/ home haemodialysis nursing team review at HHD unit (at least once every two months)
3
Establishing access cannulation
Unsuccessful cannulation after 3 attempts
Unable to proceed with haemodialysis
3
3
1
9
Potential solutions for risk mitigation
1. Education and training with individualised cannulation plan
2.Contact HHD hotline and when necessary, report to training center
3. Re-training for cannulation technique if needed
4
Cannulation technique
Defective technique in cannulating access
Acute blood loss from venous extravasation and hematoma
Vascular access infection and septicaemia
Unable to proceed with haemodialysis using vascular access
4
9
7
252
Potential solutions for risk mitigation
1. Dedicated staff for training
2. Individualised cannulation technique and type
3. Competency check during training and maintenance phase using audit tool
5
Securing vascular access
Poor fixation of needles to skin, traction of circuit line or movement especially with nocturnal dialysis
Anaemia symptoms
Acute blood loss
2
10
5
100
Potential solutions for risk mitigation
1. Discussion with patient regarding dialysis treatment plan (day time or nocturnal) and customized securing vascular access technique
2. Adequate cleaning and drying of area before cannulation [32]
3. Butterfly style taping method preferentially or in selected patient Chevron styles [33, 34]
4. Blood lines looped loosely to allow movement of patient and prevent blood lines pulling on needles especially in nocturnal dialysis [32]
5. Setting the lower limit of the venous pressure alarm as close as possible to current venous pressure alarm
6. Wetness detector, especially for nocturnal haemodialysis
7. Regular assessment of patient performing treatment observed during home visit and during physician review at HHD unit (at least once every two months)
6
Troubleshooting alarm related to vascular access
Failure to respond to arterial and venous pressure alarm
Acute blood loss
Hypotensive shock and death if excessive blood loss
3
10
6
180
Potential solutions for risk mitigation
1. Training to emphasise importance, consequences in addition to troubleshooting
2. Competency check during training and maintenance phase
3. Short concise patient education card
4. Additional devices to detect blood loss
5. A bell to notify caregiver to provide help and have a (mobile) telephone within reach to call for help
7
Monitoring vascular access during dialysis
Failure to monitor vascular access during dialysis
Vascular access thrombosis
Bleeding from needling sites
Vascular access rupture
Acute blood loss causing hypotensive shock and death if excessive blood loss
Unable to proceed with haemodialysis using vascular access
4
8
8
256
Potential solutions for risk mitigation
1. Training to patient to do basic monitoring and report on signs of infection with a clinical tool, such as Mr Victor (for dialysis catheters exit site), and pseudo-aneurysm development, with photographic evidence as appropriate
2. Emergency education to use an inverted bottle top and bandaging to limit hemorrhage from a ruptured fistula
3. Training nursing staff to perform physical examination during patient encounter (at least once every two months)
4. Appropriate pump speeds [26]
5. Vascular access monitoring during clinic review
6. Cannulation sites are determined by home HD staff along with vascular surgeon including identifying unsafe sites not for cannulation
7. Close collaboration with vascular access team
8. Call emergencies services and report to hospital emergency department if bleeding or access rupture occurs
8
Vascular access needles removal
Excessive and prolonged bleeding after removal of dialysis needles (bleeding after direct pressure applied for 10 min) [35, 36]
Anaemia symptoms
Acute blood loss
2
5
5
50
 
Potential solutions for risk mitigation
1. Education and training to patient
2. Avoid excessive anticoagulation dosages [37]
3. Removal of the needles in sequences, one needle at a time once there is no bleeding
4. Training nursing staff to perform physical examination during patient encounter (initially at least once every two months)
5. Vascular access monitoring during clinic review to exclude proximal stenosis
9
Monitoring dialysis access (general)
Failure to identify access related infection
Unable to proceed with haemodialysis using vascular access
2
8
5
80
Potential solutions for risk mitigation
1. Education and training to patient
2. Training nursing staff to perform physical examination during patient encounter (initially at least once every two months)
3. Patient to check for access viability before attempting cannulation
4. Vascular access monitoring during clinic review

Risk mitigation strategies

Table 3 provides strategies for risk mitigation of failure modes in the 9 areas related to vascular access. We identified 46 risk mitigation strategies. We discussed all areas related to vascular access with focus on the three main steps with the highest RPN (grey shading in Table 3). Some of the potential strategies for risk mitigation were overlapping.
The most significant concern was a defective technique in access cannulation that usually occurs most frequently during the early transitioning phase to HHD. We suggest risk reduction in this area needs to be initiated at the start of HHD training. In addition to identifying trained staff dedicated to HHD training, we propose an individualised vascular access approach to self-cannulation for each patient [26, 3840]. The individualised approach includes a single dedicated trainer, type of techniques, cannulation type, and weekly review during the first three months of HHD training by a designated HHD nurse with subsequent discussion with the HHD team at weekly meetings. The most suitable cannulation technique will help overcome the fear associated with cannulation and improve confidence in cannulation [4143]. Rope-ladder cannulation remains the preferred cannulation technique for HHD, and our programme encourages this over buttonhole cannulation [44]. Although buttonhole cannulation is possible for HHD patients self-needling and patients with short segment for cannulation, it should be avoided in MSSA and MRSA colonised patients [45, 46]. Patients that are MSSA and MRSA colonised should undergo successful eradication therapy before training with buttonhole cannulation. In the group of patients in the maintenance phase, the use of an audit tool using a checklist is helpful to identify patients that are at high risk for access failure and intervention and retraining [26, 4749]. As cannulation failure will not allow the patient to proceed with dialysis treatment, the patient should be instructed to abandon further attempts when appropriate, rest the access, apply ice for a minimum of 10 min and report to the training centre [50]. When possible, images of vascular access should be transferred and shared via a secured platform to assist in decision-making. If the problem cannot be readily resolved, the HHD training unit should review the patient the next day or perform a home visit.
The general vascular access alarms can be divided into venous and arterial pressure alarms. The arterial alarm may indicate line disconnection or access dysfunction, while venous alarm indicates thrombosis or clotting in the dialyzer or circuit, or kinking of lines. One of the most serious and life-threatening complications of HHD is venous needle dislodgement leading to significant blood loss, [32] and although this may not trigger the dialysis machine venous pressure alarm, wearing a wetness detector underneath the fistula alarm will trigger a separate alarm to alert the patients. As such wetness alarms are recommended for those HHD patients opting for nocturnal HHD. Training should highlight the importance of the alarms, the consequences of dismissing alarms, and troubleshooting steps. The use of educational tools such as the teach-back method should be considered to increase understanding and improve patient confidence [51, 52]. Competency checks much be performed during training and regularly in the maintenance phase. As some alarms may not often be triggered, we suggest a short and concise patient reminder card in addition to the HHD patient manual on troubleshooting these alarms as visual reminders [53, 54]. If the vascular access alarm is not resolved, patients are advised to contact HHD nursing or the technical hotline.
The recent Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Vascular Access 2019 focused on regular physical examination and checking the vascular access to detect clinical indicators of flow dysfunction by trained and experienced dialysis nurses or physicians over regular access flow monitoring [50]. In the outpatient dialysis centre, vascular access surveillance is often conducted using various devices in addition to physical examination. However, this may be limited to purely clinical examination for HHD patients. Given that the KDOQI recommendations were based on weak evidence and the concern, in particular with reports of HHD patients at higher risk of vascular access thrombosis, possibly due to a higher intensity of dialysis, such as more prolonged and more frequent dialysis sessions, we suggest teaching patients to monitor and report access dysfunction and pseudo-aneurysm formation. This needs to be supplemented by physical examination by nursing and physician review during clinic encounters and six-monthly access flow monitoring [55, 56]. When required, the HHD patient will need to undergo retraining with an audit tool to ensure that they are able to detect, record, and report access problem promptly to the HHD nursing team [47]. The HHD program should collaborate closely with the vascular access team to facilitate urgent vascular access evaluation and intervention when needed [57].

Discussion

The concept of the hospital at home (HAH) that substitutes hospital-level services at home for what would otherwise be inpatient hospitalisations has gained popularity over recent years, even locally, in Singapore [58]. Although HAH is distinctly different from HHD, which replaces an inpatient service rather than an outpatient service, the data reporting that HAH is safe and effective is promising to suggest the management of patients with acute medical illness in a home setting is safe [5961]. Nevertheless, the data on safety is still relatively limited, and management in the home setting should be considered as supplementation to a healthcare facility rather than replacement in suitable individuals [62]. World-wide, there are different approaches to HHD, with some centers restricting access to programs for patients living alone, whereas others provide assistance at home, and even help with access cannulation and decannulation. As we were initiating a HHD program de-novo, we restricted patient selection to those with fistula access and a partner or carer at home.
While HHD shares some similarities with ICHD, it also varies significantly with a more selected group of patients that are relatively healthier and having lesser human interaction involved in their treatment. The similar prescription and processes in HHD allow implementation of a system in a more controlled environment. HHD can, therefore can be undertaken safely, if not safer despite performing a high complex treatment at home. Notably, the risk and the safety strategies for HHD vary from that of ICHD [63]. While the common safety problems at ICHD were falls, medication errors, access-related, dialyser prescription errors, and excess blood loss or prolonged bleeding, we identified vascular-access as the main safety area for HHD similar to that reported by Holey et al. [64, 65]. The risk in other areas was successfully reduced by the selection and detailed planning, and framework focussing on risk reduction.
Our safety framework for the HHD program is focused mainly on risk reduction and pre-emptive evaluation. This includes strict assessment criteria for the suitability, training with frequent competency checks with individualised treatment plans for patients where appropriate, and regular checks using a standardised audit tool [25, 66, 67]. Patient selection for HHD is a defined and vigorous process and includes a thorough clinical assessment, evaluation of the home environment as well as psychosocial background [68]. Subsequent to this assessment, the patient will need to undergo a period of training, which will vary between patients, initially aiming for for 8–16 weeks with multiple clinical and theoretical competency assessments at completion of each skill and weekly. For the first haemodialysis treatment at home, a dialysis nurse and technologist will be present to observe the patient performing the session correctly and monitor for any technical errors. If there are no problems and the patient is confident after the first session, the first clinic visit will then be scheduled 4 weeks later Thereafter, clinic visits are scheduled at monthly intervals for the initial 6 months. Patients are provided 24-h nursing and technical tele consult at all times [66]. Ad-hoc home visit arrangements during office hour can be made if needed or patients will be asked to return clinic for review by physician or additional test.Home visits are scheduled to alternate between clinic visits. We used FMEA in our study to pre-emptively identify processes that can fail, prioritise failure modes with the higher risk, and set risk reduction strategies.
In terms of HHD infrastructure and equipment, there are often two or more critical stakeholders involved, with one being the contractor responsible for plumbing modifications and electrical works, and the dialysis vendor(s) providing dialysis machines, portable reverse osmosis machine and other components to the dialysis water system. Depending upon the quality of the potable water, additional or larger water softeners, carbon filters may be required depending on of the local water supply. The contractor and installation company for HHD will need to be familiar with and ensure full compliance with all regulatory requirements Adequate assessment of space and placement of equipment with regular maintenance by the vendor will reduce the risk of failure. HHD machines designs and consumables such as blood lines should be chosen with considerations for simplicity, patient-friendly set-up and interface, easy to trouble shoot with features to improve safety [66, 69]. In the event of equipment failure, repairs will be initiated at the earliest possibility, and patients will be directed to dialyse at the HHD unit under the physician’s direction.
Self-cannulation competency is the most crucial competency in completing HHD training. Failure in cannulation will not allow dialysis to be initiated regardless of competency in other areas. While assisted home dialysis, both for HHD and PD is possible,there is a significant health care cost.. The manpower cost can be prohibitive, and there may also be a shortage of dialysis trained nurses. Even if the trained staff are only required to start and finish the treatment session, the required hours including travel time for the nurse adds a significant cost factor, especially in countries with high wages. Vascular access-related events were found to have the highest RPN in our assessment of the early transition and maintenance phase of HHD. This is consistent with previous reports that vascular access is the most common category leading to severe adverse events in the HHD programme, with calls received frequently deemed severe [8, 13, 70]. We discussed the main areas with the highest RPN as agreed by the two different teams. As many of the potential risk mitigation solutions overlap, we suggest a bundle approach to addressing vascular-access related failure (Table 4). As our program matures, we intend to include patients with catheter access in the programme but this will warrant a detailed review of risk and pre-emptive risk reduction strategies.
Table 4
Summary of recommendation for vascular access
Emphasis on vascular access in education and training
Specific focus on importance, consequences and how to troubleshoot for vascular access related incidents
Dedicated staff for self-cannulation training
Individualise cannulation therapy plan
Concise patient reminder cards
24 h access to dialysis nursing and vascular access hotline
Regular vascular access checks with audit tool [47]
Close collaboration with vascular access team
Retraining when necessary
Previously published data from well-established programmes reported no correlation between the experiences of HHD programme with the occurrence of adverse events but found that these events occurred primarily in patients with some degree of HHD experience with a median vintage of two years, suggesting that there may be some degree of experimentation, serendipity, complacency, burnout, and non-compliance [13, 47, 71]. Our new programme's framework will include a minimum of two monthly reviews either at the HHD training centre or at home with an audit as the patient is dialysing. We will emphasize specific attention every two years through a thorough review using an audit tool and theoretical competency assessment and sharing incidents in the programme to highlight the importance of adherence to protocols [47]. Similarly, a two-year review of the patient’s suitability to continue HHD will be conducted to ensure safety in continuing the treatment with progression or new cognitive and psychological changes. Experienced centres have reported technical issues and human error as a contributory cause to incidents in HHD programmes [13]. While our safety framework for the program is focused mainly on risk reduction and pre-emptive evaluation, not all failures can be wholly preventable, and measures will need to be put in place for the early detection of failure with an established workflow to resolve acute problems, with a rapid evaluation cycle to prevent future occurrences. Examples of early detection and workflow for acute access-related issues will include a wetness detector, blood sensors, or needle dislocation sensors both at the access site and under the fistula arm, coupled with accessibility to technical and nursing support [72, 73]. We will be conducting regular audit of the programme going forward and conducting concise incident analysis or root cause analysis adopting a latent approach with multidisciplinary team involvement, comprising physician, nursing, quality expert, technical team, and possibly patients with each near miss or incident reported [74, 75]. The action plan will be designed for prevention and early detection. Changes to workflow will be then subsequently made as necessary, emphasizing communication to all patients regarding any changes in a timely manner.
Failure mode and effects analysis (FMEA) is a proactive risk management tool for identifying the possible failure modes of a system, process, product or service, analysing the causes and effects of the failures, and eliminating or reducing the most significant ones by proposing risk mitigation actions [76]. FMEA is effective in evaluating both new and existing processes and systems. While FMEA has not been validated for HHD, we have used FMEA as an assessment tool before starting a new clinical program focussing on processes with highest risk. Given that there was no prior experience in HHD at our hospital, we sought collaboration from another unit. The involvement of the two HHD teams with different experiences and perspectives is unique and is also the strength of our study. It generates the opportunity to review HHD as a start-up with different challenges and to use the lessons from a mature HHD programme to help craft solutions to these challenges. The collaboration between the two teams provided an excellent platform for sharing and discussion as we focused on the safety aspects of our pilot HHD programme. The minor difference between HHD vascular access management between the two programmes are outlined in Table 5.
Table 5
Outline of differences between vascular access management in new and an established HHD programme
 
New HHD programme
Established HHD programme
Frequency of review
Monthly for the first 3 months then, 2 monthly clinic review and physical examination of vascular access by HHD nurse and physician
3 monthly review of vascular access by vascular surgeon with vascular access scans if necessary
6 monthly clinic review and physical examination of vascular access by HHD nurse
Competency assessment
2 monthly review alternating home visit and HHD centre review by both HHD nurse and physician
6 monthly review alternating home visit and HHD centre review by HHD nurse
Although the processes of HHD are similar in many instances, the ability to generalise the failure modes and potential solutions for risk mitigation in two different settings may limit our study findings. There are inherent differences in our population in terms of logistics, demographics, and even simple differences such as climate and housing compared to that in London. To reduce unknown confounders related to these differences, we aim to conduct a second FMEA after starting our HHD programme and to examine our suggested solutions prospectively.

Conclusions

Although HHD may appear to be a complex treatment performed by patients at home without direct supervision, HHD is a safe therapy as evident by its past record. Enhancing safety and patient experience will encourage and motivate patient to choose HHD [55]. The reported adverse incidents are similar to that of ICHD. However, HHD patients must have the ability to manage any treatment related complications occurring at home, occasionally with the presence of a caregiver and hence, the enhanced focus on safety and the reason for this FMEA approach. Our study reports the use of FMEA with the involvement of two teams, at different ends of the clinical experience scale in HHD. We summarize here the risk assessment of possible areas of failure in starting HHD from different perspectives. The risk reduction strategies are not new, but we have designed a framework that addresses the specific areas in a bundle approach. As vascular access related medical emergencies were the most prominent in our risk assessment, our FMEA was primarily directed to this area of risk and we successfully identified risk reduction strategies.

Acknowledgements

We would like to thank all individuals, professionals and patients who helped in the assessment of the FMEA system HHD. We would like to thank members of the Royal Free Hospital Haemodialysis program: Mr J Duatin, Mr M Gerard, Mr F Haves and Mr G Murcutt.

Declarations

Failure mode effect analysis does not meet the definition of human-subject research, and approval for the conduct of this study was not required.
Not applicable.

Competing interests

The authors declare that they have no conflicts of interest.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Literatur
1.
Zurück zum Zitat Rydell H, Ivarsson K, Almquist M, Segelmark M, Clyne N. Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study. BMC Nephrol. 2019;20(1):52.CrossRef Rydell H, Ivarsson K, Almquist M, Segelmark M, Clyne N. Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study. BMC Nephrol. 2019;20(1):52.CrossRef
2.
Zurück zum Zitat Rydell H, Ivarsson K, Almquist M, Clyne N, Segelmark M. Fewer hospitalizations and prolonged technique survival with home hemodialysis- a matched cohort study from the Swedish renal registry. BMC Nephrol. 2019;20(1):480.CrossRef Rydell H, Ivarsson K, Almquist M, Clyne N, Segelmark M. Fewer hospitalizations and prolonged technique survival with home hemodialysis- a matched cohort study from the Swedish renal registry. BMC Nephrol. 2019;20(1):480.CrossRef
3.
Zurück zum Zitat Masterson R. The advantages and disadvantages of home hemodialysis. Hemodial Int. 2008;12(Suppl 1):S16-20.CrossRef Masterson R. The advantages and disadvantages of home hemodialysis. Hemodial Int. 2008;12(Suppl 1):S16-20.CrossRef
4.
Zurück zum Zitat Watanabe Y, Ohno Y, Inoue T, Takane H, Okada H, Suzuki H. Home hemodialysis and conventional in-center hemodialysis in Japan: a comparison of health-related quality of life. Hemodial Int. 2014;18(Suppl 1):S32–8.CrossRef Watanabe Y, Ohno Y, Inoue T, Takane H, Okada H, Suzuki H. Home hemodialysis and conventional in-center hemodialysis in Japan: a comparison of health-related quality of life. Hemodial Int. 2014;18(Suppl 1):S32–8.CrossRef
5.
Zurück zum Zitat Pauly RP, Gill JS, Rose CL, Asad RA, Chery A, Pierratos A, et al. Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients. Nephrol Dial Transplant. 2009;24(9):2915–9.CrossRef Pauly RP, Gill JS, Rose CL, Asad RA, Chery A, Pierratos A, et al. Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients. Nephrol Dial Transplant. 2009;24(9):2915–9.CrossRef
6.
Zurück zum Zitat Nishio-Lucar AG, Bose S, Lyons G, Awuah KT, Ma JZ, Lockridge RS Jr. Intensive home hemodialysis survival comparable to deceased donor kidney transplantation. Kidney Int Rep. 2020;5(3):296–306.CrossRef Nishio-Lucar AG, Bose S, Lyons G, Awuah KT, Ma JZ, Lockridge RS Jr. Intensive home hemodialysis survival comparable to deceased donor kidney transplantation. Kidney Int Rep. 2020;5(3):296–306.CrossRef
7.
Zurück zum Zitat Sands JJ, Lacson E Jr, Ofsthun NJ, Kay JC, Diaz-Buxo JA. Home hemodialysis: a comparison of in-center and home hemodialysis therapy in a cohort of successful home hemodialysis patients. ASAIO J. 2009;55(4):361–8.CrossRef Sands JJ, Lacson E Jr, Ofsthun NJ, Kay JC, Diaz-Buxo JA. Home hemodialysis: a comparison of in-center and home hemodialysis therapy in a cohort of successful home hemodialysis patients. ASAIO J. 2009;55(4):361–8.CrossRef
8.
Zurück zum Zitat Kraus M, Burkart J, Hegeman R, Solomon R, Coplon N, Moran J. A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease. Hemodial Int. 2007;11(4):468–77.CrossRef Kraus M, Burkart J, Hegeman R, Solomon R, Coplon N, Moran J. A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease. Hemodial Int. 2007;11(4):468–77.CrossRef
9.
Zurück zum Zitat Haroon S, Griva K, Davenport A. Factors affecting uptake of home hemodialysis among self-care dialysis unit patients. Hemodial Int. 2020;24(4):460–9.CrossRef Haroon S, Griva K, Davenport A. Factors affecting uptake of home hemodialysis among self-care dialysis unit patients. Hemodial Int. 2020;24(4):460–9.CrossRef
10.
Zurück zum Zitat Lee A, Gudex C, Povlsen JV, Bonnevie B, Nielsen CP. Patients’ views regarding choice of dialysis modality. Nephrol Dial Transplant. 2008;23(12):3953–9.CrossRef Lee A, Gudex C, Povlsen JV, Bonnevie B, Nielsen CP. Patients’ views regarding choice of dialysis modality. Nephrol Dial Transplant. 2008;23(12):3953–9.CrossRef
11.
Zurück zum Zitat Keating PT, Walsh M, Ribic CM, Brimble KS. The impact of patient preference on dialysis modality and hemodialysis vascular access. BMC Nephrol. 2014;15:38.CrossRef Keating PT, Walsh M, Ribic CM, Brimble KS. The impact of patient preference on dialysis modality and hemodialysis vascular access. BMC Nephrol. 2014;15:38.CrossRef
12.
Zurück zum Zitat Office NROD. Singapore renal registry annual report 2018. 2018. Office NROD. Singapore renal registry annual report 2018. 2018.
13.
Zurück zum Zitat Wong B, Zimmerman D, Reintjes F, Courtney M, Klarenbach S, Dowling G, et al. Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective. Am J Kidney Dis. 2014;63(2):251–8.CrossRef Wong B, Zimmerman D, Reintjes F, Courtney M, Klarenbach S, Dowling G, et al. Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective. Am J Kidney Dis. 2014;63(2):251–8.CrossRef
14.
Zurück zum Zitat Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Patient Saf. 2009;5(2):86–94.CrossRef Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Patient Saf. 2009;5(2):86–94.CrossRef
15.
Zurück zum Zitat Bonfant G, Belfanti P, Paternoster G, Gabrielli D, Gaiter AM, Manes M, et al. Clinical risk analysis with failure mode and effect analysis (FMEA) model in a dialysis unit. J Nephrol. 2010;23(1):111–8. Bonfant G, Belfanti P, Paternoster G, Gabrielli D, Gaiter AM, Manes M, et al. Clinical risk analysis with failure mode and effect analysis (FMEA) model in a dialysis unit. J Nephrol. 2010;23(1):111–8.
16.
Zurück zum Zitat Martin LD, Grigg EB, Verma S, Latham GJ, Rampersad SE, Martin LD. Outcomes of a failure mode and effects analysis for medication errors in pediatric anesthesia. Paediatr Anaesth. 2017;27(6):571–80.CrossRef Martin LD, Grigg EB, Verma S, Latham GJ, Rampersad SE, Martin LD. Outcomes of a failure mode and effects analysis for medication errors in pediatric anesthesia. Paediatr Anaesth. 2017;27(6):571–80.CrossRef
17.
Zurück zum Zitat Potts HW, Anderson JE, Colligan L, Leach P, Davis S, Berman J. Assessing the validity of prospective hazard analysis methods: a comparison of two techniques. BMC Health Serv Res. 2014;14:41.CrossRef Potts HW, Anderson JE, Colligan L, Leach P, Davis S, Berman J. Assessing the validity of prospective hazard analysis methods: a comparison of two techniques. BMC Health Serv Res. 2014;14:41.CrossRef
18.
Zurück zum Zitat Joint Commission Resources Inc. Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction. 3rd edition. Joint Commission Resources, Oakbrook Terrace, IL; 2010. Joint Commission Resources Inc. Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction. 3rd edition. Joint Commission Resources, Oakbrook Terrace, IL; 2010.
19.
Zurück zum Zitat Ashley L, Armitage G, Neary M, Hollingsworth G. A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings. Jt Comm J Qual Patient Saf. 2010;36(8):351–8. Ashley L, Armitage G, Neary M, Hollingsworth G. A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings. Jt Comm J Qual Patient Saf. 2010;36(8):351–8.
21.
Zurück zum Zitat Ho CC, Liao CJ. The use of failure mode and effects analysis to construct an effective disposal and prevention mechanism for infectious hospital waste. Waste Manag. 2011;31(12):2631–7.CrossRef Ho CC, Liao CJ. The use of failure mode and effects analysis to construct an effective disposal and prevention mechanism for infectious hospital waste. Waste Manag. 2011;31(12):2631–7.CrossRef
22.
Zurück zum Zitat Li X, He M, Wang H. Application of failure mode and effect analysis in managing catheter-related blood stream infection in intensive care unit. Medicine (Baltimore). 2017;96(51): e9339.CrossRef Li X, He M, Wang H. Application of failure mode and effect analysis in managing catheter-related blood stream infection in intensive care unit. Medicine (Baltimore). 2017;96(51): e9339.CrossRef
23.
Zurück zum Zitat Labriola L, Crott R, Desmet C, Andre G, Jadoul M. Infectious complications following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement report. Am J Kidney Dis. 2011;57(3):442–8.CrossRef Labriola L, Crott R, Desmet C, Andre G, Jadoul M. Infectious complications following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement report. Am J Kidney Dis. 2011;57(3):442–8.CrossRef
24.
Zurück zum Zitat Kaplowitz LG, Comstock JA, Landwehr DM, Dalton HP, Mayhall CG. Prospective study of microbial colonization of the nose and skin and infection of the vascular access site in hemodialysis patients. J Clin Microbiol. 1988;26(7):1257–62.CrossRef Kaplowitz LG, Comstock JA, Landwehr DM, Dalton HP, Mayhall CG. Prospective study of microbial colonization of the nose and skin and infection of the vascular access site in hemodialysis patients. J Clin Microbiol. 1988;26(7):1257–62.CrossRef
25.
Zurück zum Zitat Nesrallah GE, Mustafa RA, MacRae J, Pauly RP, Perkins DN, Gangji A, et al. Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis. Am J Kidney Dis. 2013;62(1):187–98.CrossRef Nesrallah GE, Mustafa RA, MacRae J, Pauly RP, Perkins DN, Gangji A, et al. Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis. Am J Kidney Dis. 2013;62(1):187–98.CrossRef
26.
Zurück zum Zitat Faratro R, Jeffries J, Nesrallah GE, MacRae JM. The care and keeping of vascular access for home hemodialysis patients. Hemodial Int. 2015;19(Suppl 1):S80-92.CrossRef Faratro R, Jeffries J, Nesrallah GE, MacRae JM. The care and keeping of vascular access for home hemodialysis patients. Hemodial Int. 2015;19(Suppl 1):S80-92.CrossRef
27.
Zurück zum Zitat Vascular Access Special Interest Group BRS. Clinical practice recommendations for use of buttonhole technique for cannulation of arteriovenous fistulae. 2016. Vascular Access Special Interest Group BRS. Clinical practice recommendations for use of buttonhole technique for cannulation of arteriovenous fistulae. 2016.
28.
Zurück zum Zitat Kang JS, Jang HR, Lee JE, Park YJ, Rhee H, Seong EY, et al. The bacterial colonization in tunneled cuffed dialysis catheter and its effects on residual renal function in incident hemodialysis patients. Clin Exp Nephrol. 2016;20(2):294–301.CrossRef Kang JS, Jang HR, Lee JE, Park YJ, Rhee H, Seong EY, et al. The bacterial colonization in tunneled cuffed dialysis catheter and its effects on residual renal function in incident hemodialysis patients. Clin Exp Nephrol. 2016;20(2):294–301.CrossRef
29.
Zurück zum Zitat Kang YC, Tai WC, Yu CC, Kang JH, Huang YC. Methicillin-resistant Staphylococcus aureus nasal carriage among patients receiving hemodialysis in Taiwan: prevalence rate, molecular characterization and de-colonization. BMC Infect Dis. 2012;12:284.CrossRef Kang YC, Tai WC, Yu CC, Kang JH, Huang YC. Methicillin-resistant Staphylococcus aureus nasal carriage among patients receiving hemodialysis in Taiwan: prevalence rate, molecular characterization and de-colonization. BMC Infect Dis. 2012;12:284.CrossRef
30.
Zurück zum Zitat Narasimha Krishna V, Allon M. What is the significance of Staphylococcus aureus colonization in hemodialysis patients? Nephron. 2015;129(2):75–8.CrossRef Narasimha Krishna V, Allon M. What is the significance of Staphylococcus aureus colonization in hemodialysis patients? Nephron. 2015;129(2):75–8.CrossRef
31.
Zurück zum Zitat Nesrallah GE, Cuerden M, Wong JH, Pierratos A. Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis. Clin J Am Soc Nephrol. 2010;5(6):1047–53.CrossRef Nesrallah GE, Cuerden M, Wong JH, Pierratos A. Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis. Clin J Am Soc Nephrol. 2010;5(6):1047–53.CrossRef
32.
Zurück zum Zitat Van Waeleghem JP, Chamney M, Lindley EJ, Pancirova J. Venous needle dislodgement: how to minimise the risks. J Ren Care. 2008;34(4):163–8.CrossRef Van Waeleghem JP, Chamney M, Lindley EJ, Pancirova J. Venous needle dislodgement: how to minimise the risks. J Ren Care. 2008;34(4):163–8.CrossRef
33.
Zurück zum Zitat Chan DYF, Dobson S, Barber T. Hemodialysis taping styles and their effect on reducing the chance of venous needle dislodgement. Semin Dial. 2021;34(3):218–23.CrossRef Chan DYF, Dobson S, Barber T. Hemodialysis taping styles and their effect on reducing the chance of venous needle dislodgement. Semin Dial. 2021;34(3):218–23.CrossRef
35.
Zurück zum Zitat Hodde L, Sandroni S. Emergency department evaluation and management of dialysis patient complications. J Emerg Med. 1992;10:317–34.CrossRef Hodde L, Sandroni S. Emergency department evaluation and management of dialysis patient complications. J Emerg Med. 1992;10:317–34.CrossRef
37.
Zurück zum Zitat Davenport A. What are the anticoagulation options for intermittent hemodialysis? Nat Rev Nephrol. 2011;7(9):499–508.CrossRef Davenport A. What are the anticoagulation options for intermittent hemodialysis? Nat Rev Nephrol. 2011;7(9):499–508.CrossRef
38.
Zurück zum Zitat Karkar A, Hegbrant J, Strippoli GF. Benefits and implementation of home hemodialysis: a narrative review. Saudi J Kidney Dis Transpl. 2015;26(6):1095–107.CrossRef Karkar A, Hegbrant J, Strippoli GF. Benefits and implementation of home hemodialysis: a narrative review. Saudi J Kidney Dis Transpl. 2015;26(6):1095–107.CrossRef
39.
Zurück zum Zitat Mott S, Moore H. Using “Tandem hand” technique to facilitate self-cannulation in hemodialysis. Nephrol Nurs J. 2009;36(3):313–6 , 25. Mott S, Moore H. Using “Tandem hand” technique to facilitate self-cannulation in hemodialysis. Nephrol Nurs J. 2009;36(3):313–6 , 25.
40.
Zurück zum Zitat Verhallen AM, Kooistra MP, van Jaarsveld BC. Cannulating in haemodialysis: rope-ladder or buttonhole technique? Nephrol Dial Transplant. 2007;22(9):2601–4.CrossRef Verhallen AM, Kooistra MP, van Jaarsveld BC. Cannulating in haemodialysis: rope-ladder or buttonhole technique? Nephrol Dial Transplant. 2007;22(9):2601–4.CrossRef
41.
Zurück zum Zitat Mott S, Schatell D, Patterson P, Last FM. Techniques for self-cannulation. Nephrol Nurs J. 2020;47(5):483–7.CrossRef Mott S, Schatell D, Patterson P, Last FM. Techniques for self-cannulation. Nephrol Nurs J. 2020;47(5):483–7.CrossRef
42.
Zurück zum Zitat Staaf K, Fernstrom A, Uhlin F. Cannulation technique and complications in arteriovenous fistulas: a Swedish renal registry-based cohort study. BMC Nephrol. 2021;22(1):256.CrossRef Staaf K, Fernstrom A, Uhlin F. Cannulation technique and complications in arteriovenous fistulas: a Swedish renal registry-based cohort study. BMC Nephrol. 2021;22(1):256.CrossRef
43.
Zurück zum Zitat Casey JR, Hanson CS, Winkelmayer WC, Craig JC, Palmer S, Strippoli GF, et al. Patients’ perspectives on hemodialysis vascular access: a systematic review of qualitative studies. Am J Kidney Dis. 2014;64(6):937–53.CrossRef Casey JR, Hanson CS, Winkelmayer WC, Craig JC, Palmer S, Strippoli GF, et al. Patients’ perspectives on hemodialysis vascular access: a systematic review of qualitative studies. Am J Kidney Dis. 2014;64(6):937–53.CrossRef
44.
Zurück zum Zitat Wong B, Muneer M, Wiebe N, Storie D, Shurraw S, Pannu N, et al. Buttonhole versus rope-ladder cannulation of arteriovenous fistulas for hemodialysis: a systematic review. Am J Kidney Dis. 2014;64(6):918–36.CrossRef Wong B, Muneer M, Wiebe N, Storie D, Shurraw S, Pannu N, et al. Buttonhole versus rope-ladder cannulation of arteriovenous fistulas for hemodialysis: a systematic review. Am J Kidney Dis. 2014;64(6):918–36.CrossRef
45.
Zurück zum Zitat Lyman M, Nguyen DB, Shugart A, Gruhler H, Lines C, Patel PR. Risk of vascular access infection associated with buttonhole cannulation of fistulas: data from the national healthcare safety network. Am J Kidney Dis. 2020;76(1):82–9.CrossRef Lyman M, Nguyen DB, Shugart A, Gruhler H, Lines C, Patel PR. Risk of vascular access infection associated with buttonhole cannulation of fistulas: data from the national healthcare safety network. Am J Kidney Dis. 2020;76(1):82–9.CrossRef
46.
Zurück zum Zitat Grudzinski A, Mendelssohn D, Pierratos A, Nesrallah G. A systematic review of buttonhole cannulation practices and outcomes. Semin Dial. 2013;26(4):465–75.CrossRef Grudzinski A, Mendelssohn D, Pierratos A, Nesrallah G. A systematic review of buttonhole cannulation practices and outcomes. Semin Dial. 2013;26(4):465–75.CrossRef
47.
Zurück zum Zitat Rousseau-Gagnon M, Faratro R, D’Gama C, Fung S, Wong E, Chan CT. The use of vascular access audit and infections in home hemodialysis. Hemodial Int. 2016;20(2):298–305.CrossRef Rousseau-Gagnon M, Faratro R, D’Gama C, Fung S, Wong E, Chan CT. The use of vascular access audit and infections in home hemodialysis. Hemodial Int. 2016;20(2):298–305.CrossRef
50.
Zurück zum Zitat Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–164.CrossRef Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–164.CrossRef
51.
Zurück zum Zitat Ryan-Madonna M, Levin RF, Lauder B. Effectiveness of the teach-back method for improving caregivers’ confidence in caring for hospice patients and decreasing hospitalizations. J Hosp Palliat Nurs. 2019;21(1):61–70.CrossRef Ryan-Madonna M, Levin RF, Lauder B. Effectiveness of the teach-back method for improving caregivers’ confidence in caring for hospice patients and decreasing hospitalizations. J Hosp Palliat Nurs. 2019;21(1):61–70.CrossRef
52.
Zurück zum Zitat Yen PH, Leasure AR. Use and effectiveness of the teach-back method in patient education and health outcomes. Fed Pract. 2019;36(6):284–9. Yen PH, Leasure AR. Use and effectiveness of the teach-back method in patient education and health outcomes. Fed Pract. 2019;36(6):284–9.
53.
Zurück zum Zitat Chae SY, Chae MH, Isaacson N, James TS. The patient medication list: can we get patients more involved in their medical care? J Am Board Fam Med. 2009;22(6):677–85.CrossRef Chae SY, Chae MH, Isaacson N, James TS. The patient medication list: can we get patients more involved in their medical care? J Am Board Fam Med. 2009;22(6):677–85.CrossRef
54.
Zurück zum Zitat Lachowsky M, Levy-Toledano R. Improving compliance in oral contraception: “the reminder card.” Eur J Contracept Reprod Health Care. 2002;7(4):210–5.CrossRef Lachowsky M, Levy-Toledano R. Improving compliance in oral contraception: “the reminder card.” Eur J Contracept Reprod Health Care. 2002;7(4):210–5.CrossRef
55.
Zurück zum Zitat Rocco MV, Lockridge RS Jr, Beck GJ, Eggers PW, Gassman JJ, Greene T, et al. The effects of frequent nocturnal home hemodialysis: the frequent hemodialysis network nocturnal trial. Kidney Int. 2011;80(10):1080–91.CrossRef Rocco MV, Lockridge RS Jr, Beck GJ, Eggers PW, Gassman JJ, Greene T, et al. The effects of frequent nocturnal home hemodialysis: the frequent hemodialysis network nocturnal trial. Kidney Int. 2011;80(10):1080–91.CrossRef
56.
Zurück zum Zitat Group FHNT, Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24):2287–300.CrossRef Group FHNT, Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24):2287–300.CrossRef
57.
Zurück zum Zitat Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP, et al. Editor’s choice - vascular access: 2018 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(6):757–818.CrossRef Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP, et al. Editor’s choice - vascular access: 2018 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(6):757–818.CrossRef
58.
Zurück zum Zitat Lai YF, Lim YW, Kuan WS, Goh J, Soong JTY, Shorey S, Ko SQ. Asian attitudes and perceptions toward hospital-at-home: a cross-sectional study. Front Public Health. 2021;23(9): 704465.CrossRef Lai YF, Lim YW, Kuan WS, Goh J, Soong JTY, Shorey S, Ko SQ. Asian attitudes and perceptions toward hospital-at-home: a cross-sectional study. Front Public Health. 2021;23(9): 704465.CrossRef
60.
Zurück zum Zitat Rickert J. On patient safety: hospital-at-home care seems like a winner, but is it safe for our patients? Clin Orthop Relat Res. 2022;480(2):237–40.CrossRef Rickert J. On patient safety: hospital-at-home care seems like a winner, but is it safe for our patients? Clin Orthop Relat Res. 2022;480(2):237–40.CrossRef
61.
Zurück zum Zitat Montalto M. How safe is hospital-in-the-home care? Med J Aust. 1998;168(6):277–80.CrossRef Montalto M. How safe is hospital-in-the-home care? Med J Aust. 1998;168(6):277–80.CrossRef
62.
Zurück zum Zitat Foley OW, Ferris TG, Thompson RW, Heng M, Ricciardi R, Del Carmen MG, Safavi KC. Potential impact of hospital at home on postoperative readmissions. Am J Manag Care. 2021;27(12):e420–5.CrossRef Foley OW, Ferris TG, Thompson RW, Heng M, Ricciardi R, Del Carmen MG, Safavi KC. Potential impact of hospital at home on postoperative readmissions. Am J Manag Care. 2021;27(12):e420–5.CrossRef
63.
Zurück zum Zitat Arenas Jimenez MD, Ferre G, Alvarez-Ude F. Strategies to increase patient safety in hemodialysis: application of the modal analysis system of errors and effects (FEMA system). Nefrologia. 2017;37(6):608–21. Arenas Jimenez MD, Ferre G, Alvarez-Ude F. Strategies to increase patient safety in hemodialysis: application of the modal analysis system of errors and effects (FEMA system). Nefrologia. 2017;37(6):608–21.
64.
Zurück zum Zitat Holley JL. A descriptive report of errors and adverse events in chronic hemodialysis units. Nephrol News Issues. 2006;20(12):57–8 60–1, 3 passim. Holley JL. A descriptive report of errors and adverse events in chronic hemodialysis units. Nephrol News Issues. 2006;20(12):57–8 60–1, 3 passim.
65.
Zurück zum Zitat Garrick R, Kliger A, Stefanchik B. Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety. Clin J Am Soc Nephrol. 2012;7(4):680–8.CrossRef Garrick R, Kliger A, Stefanchik B. Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety. Clin J Am Soc Nephrol. 2012;7(4):680–8.CrossRef
66.
Zurück zum Zitat Rajkomar A, Farrington K, Mayer A, Walker D, Blandford A. Patients’ and carers’ experiences of interacting with home haemodialysis technology: implications for quality and safety. BMC Nephrol. 2014;15:195.CrossRef Rajkomar A, Farrington K, Mayer A, Walker D, Blandford A. Patients’ and carers’ experiences of interacting with home haemodialysis technology: implications for quality and safety. BMC Nephrol. 2014;15:195.CrossRef
67.
Zurück zum Zitat Agarwal AK, Boubes KY, Haddad NF. Essentials of vascular access for home hemodialysis. Adv Chronic Kidney Dis. 2021;28(2):164–9.CrossRef Agarwal AK, Boubes KY, Haddad NF. Essentials of vascular access for home hemodialysis. Adv Chronic Kidney Dis. 2021;28(2):164–9.CrossRef
68.
Zurück zum Zitat Rioux JP, Marshall MR, Faratro R, Hakim R, Simmonds R, Chan CT. Patient selection and training for home hemodialysis. Hemodial Int. 2015;19(Suppl 1):S71–9.CrossRef Rioux JP, Marshall MR, Faratro R, Hakim R, Simmonds R, Chan CT. Patient selection and training for home hemodialysis. Hemodial Int. 2015;19(Suppl 1):S71–9.CrossRef
69.
Zurück zum Zitat Haroon S, Davenport A. Haemodialysis at home: review of current dialysis machines. Expert Rev Med Devices. 2018;15(5):337–47.CrossRef Haroon S, Davenport A. Haemodialysis at home: review of current dialysis machines. Expert Rev Med Devices. 2018;15(5):337–47.CrossRef
70.
Zurück zum Zitat Reintjes F, Herian N, Shah N, Pauly RP. Prospective monitoring of after-hours nursing and technologist support calls to a regional Canadian home hemodialysis program. Hemodial Int. 2019;23(1):19–25.CrossRef Reintjes F, Herian N, Shah N, Pauly RP. Prospective monitoring of after-hours nursing and technologist support calls to a regional Canadian home hemodialysis program. Hemodial Int. 2019;23(1):19–25.CrossRef
71.
Zurück zum Zitat Hawley CM, Jeffries J, Nearhos J, Van Eps C. Complications of home hemodialysis. Hemodial Int. 2008;12(Suppl 1):S21–5.CrossRef Hawley CM, Jeffries J, Nearhos J, Van Eps C. Complications of home hemodialysis. Hemodial Int. 2008;12(Suppl 1):S21–5.CrossRef
72.
Zurück zum Zitat Polaschegg HD. Venous needle dislodgement: the pitfalls of venous pressure measurement and possible alternatives, a review. J Ren Care. 2010;36(1):41–8.CrossRef Polaschegg HD. Venous needle dislodgement: the pitfalls of venous pressure measurement and possible alternatives, a review. J Ren Care. 2010;36(1):41–8.CrossRef
73.
Zurück zum Zitat Ahlmen J, Gydell KH, Hadimeri H, Hernandez I, Rogland B, Strombom U. A new safety device for hemodialysis. Hemodial Int. 2008;12(2):264–7.CrossRef Ahlmen J, Gydell KH, Hadimeri H, Hernandez I, Rogland B, Strombom U. A new safety device for hemodialysis. Hemodial Int. 2008;12(2):264–7.CrossRef
74.
Zurück zum Zitat Leape LL. A systems analysis approach to medical error. J Eval Clin Pract. 1997;3(3):213–22.CrossRef Leape LL. A systems analysis approach to medical error. J Eval Clin Pract. 1997;3(3):213–22.CrossRef
76.
Zurück zum Zitat Stamatis DH. Failure Mode and Effect Analysis: FMEA from Theory to Execution. 2nd ed. New York: ASQ Quality Press; 2023. Stamatis DH. Failure Mode and Effect Analysis: FMEA from Theory to Execution. 2nd ed. New York: ASQ Quality Press; 2023.
Metadaten
Titel
Risk assessment of failure during transitioning from in-centre to home haemodialysis
verfasst von
Sabrina-Wong-Peixin Haroon
Titus-Wai-Leong Lau
Gan Liang Tan
Eugene-Hern Choon Liu
Soh Heng Hui
Siao Luan Lim
Diana Santos
Robyn Hodgson
Lindsay Taylor
Jia Neng Tan
Andrew Davenport
FH HHD
Publikationsdatum
01.12.2022
Verlag
BioMed Central
Erschienen in
BMC Nephrology / Ausgabe 1/2022
Elektronische ISSN: 1471-2369
DOI
https://doi.org/10.1186/s12882-022-03039-4

Weitere Artikel der Ausgabe 1/2022

BMC Nephrology 1/2022 Zur Ausgabe

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.