This is part of Nephrology Leadership Program organized by the Iraqi Ministry of Health

1. Leadership & Management
Nephrology- Patient Safety
Dr. Ala Sh. Ali
Consultant Nephrologist and Transplant Physician
Nephrology and Renal Transplantation Centre
The Medical City
Nephrology Leadership Program – Ministry of Health , Part 3 August, 2019

2. «‫التوابون‬ ‫ائين‬ّ‫ط‬‫الخ‬ ‫وخير‬ ،‫خطاء‬ ‫آدم‬ ‫بني‬ ‫كل‬»
ْ‫ي‬ ِ‫ح‬َّ‫الر‬ ِ‫ن‬َ‫م‬ْ‫ح‬َّ‫الر‬ ِ‫هللا‬ ِ‫م‬ْ‫س‬ِ‫ب‬ِ‫م‬
‫العظيم‬ ‫هللا‬ ‫صدق‬

3. Why we should know about Patient Safety?
The incidence and nature of in-hospital adverse events: a systematic
review BMJ 2007
Adverse events during hospital admission are a serious
problem, occurring in approximately 9% of all admitted
patients and leading to a lethal outcome in 7% of cases. Since
alarge portion of the adverse events are operation- or drug-
related, and almost half of these events are preventable,
funds and efforts should be concentrated on interventions
aimed atreducing these types of events.

4. Definitions
Safety : the concept of avoidable harm as a direct result
of health care, rather than harm resulting directly from
the condition for which care is being given.
Harm: An act that causes loss or pain. It can be used of
anything that causes suffering or loss. To cause physical
or mental damage

5. Iceberg Model of Accidents and Errors
Serious Events
Death/Severe Harm
Near Miss
Unwanted consequence
prevented because of recovery
No Harm Events

7. Examples
Errors in Commission
• Adverse reactions to drugs,
• Drug interactions,
• Retained surgical instruments
• Interventions which result in
accelerated loss of kidney
function
Errors in Ommission
• No start of anticoagulation
• Failure to adhere to catheter
care procedure
• Late referral to nephrology care

9. Potential errors in CKD-HD practice
CKD patients are at increased risk of defined Patient Safety Pndicators:
• Hip fracture,
• Post-operative metabolic or physiological derangement,
• Complications of anesthesia,
• Infections,
• Hyperkalemia,
• Hypoglycemia,
• Drug prescription errors, and
• Etc ….

10. How safe is renal replacement therapy? Evidence
Events that may have or did contribute to the death of a patient were
identified in 47 (3.6%) deaths within the cohort as a whole, and in
38(4%) inpatient deaths.

11. What we need to do ?
1. We should have the courage to say ; there is a problem
2. Diagnosis ;using different analysis tools.
3. Nephrologists, and the teams they work with, must accept
the ‘burden of improvement’.

12. How to implement ?
1. The precise solution depends on the Hospital Setting
2. Actively encouraging junior doctors to participate, to ask
for help and to look after change.
3. Teamwork
4. Standardization of care, with clearly written, accessible,
protocols and clinical practice guidelines is also important,
particularly for junior doctors working out of hours.
5. Ensuring adherence to guidelines