Wrong Reuse dialyzer Wrong Patient

[qwerty]

does anyone have copy of Davita's P & P on checks of reuse dialyzers prior to putting pt on. Also what are your protocols for when the wrong re-use dialyzer is placed on another patient step by step? Also risk to patient if he recieves another patients re-use dialzyer? I need specifics for documentation if anyone is able to help. This is primarily related to a chart review in which pt recieved wrong patients dialzyer. Thanks ahead of time

[bioya]

I don't have it but last time I was FA and that subject come up the dialysizer had to be checked by two employees (oops teammembers) and initial the sticker that it was the correct one. That was awhile back and things may have changed.

does anyone have copy of Davita's P & P on checks of reuse dialyzers prior to putting pt on. Also what are your protocols for when the wrong re-use dialyzer is placed on another patient step by step? Also risk to patient if he recieves another patients re-use dialzyer? I need specifics for documentation if anyone is able to help. This is primarily related to a chart review in which pt recieved wrong patients dialzyer. Thanks ahead of time

[kitkatz]

Patient should also be checking the dialyzer before sitting down in the chair.

[sico]

When I was on HD here in Australia they used a new one every time, totally avoids this situation ever arising.

[qwerty]

Thank you as I'm looking for specifics due a case review for an attorney. I can have the attorney petition the info but takes very long to do dependant on the specific clinics cooperation. I was hoping someone had Davitas follow-up of what happens once the error is realized and thier protocol afterwards so I can move my report quicker. Such as incident report, blood work protocol etc.  Davita utilizes re-use in the area in question so that's what I have to concentrate on. The non-davita clinic I work for uses dry packs. I havent worked for Davita in awhile so imagine somethings have changed.

[nursewratchet]

Two person checks and initials.  The patient also checks and initials.  IF the patient is put on wrong dialyzer:  Patient is NOT rinsed back.  Patient given Saline.  Put on a dry pack.  Labs are drawn: CBC and K+. (stat). Hep and HIV labs are drawn on the "OTHER" patient, if they consent.   MD of course is called.  The initial "risk of reuse" consent is reread to patient and copies given.  AFTER labs are drawn, if patient is symptomatic, are sent to ER.  Risk management is notified, incident report is filled out.  The dialyzer and lines are saved in fridge until risk management investigates the incident.  It is then discarded and not processed. 
As far as the employee is concerned, the process is suspension until further investigation.  Usually termed.  That is out of step for corrective action, but anytime ther is a safety concern, it is an immediate suspension.  I've NEVER had anyone come back from a suspension.  Hope this helps...

[qwerty]

Thank you very much Nursewratchet!!!  It will help a great deal with my review and report. Pt wasnt notified until a week later and it was only by a slipup from another staff member that he was.He noticed them messing with machine and changing things out the day of the occurence and asked what the issue was. He was told "its just a machine issue".  None of the above done from what I can tell. In fact it appears it may have been swept under the rug so to speak. Thing is if I remember correctly Snappy wont allow you to move forward on charting until the initials are in documenting the check for dialyzer and renalin check, therefore it was documented without doing the appropriate checks per guidelines? I appreciate your help.

[Zach]

Another reason not to continue with a reuse program.