Human Error

[gothiclovemonkey]

I know the potential for human error is pretty high, and that scares me very much, probably the worst part about having dialysis.
Between being infultrated, computer mistakes, putting the wrong info in to the machine, its just scary!

Just the other day,saturday? they got me on the machine, id been on for 15 mins, and she comes over to say, i have to take u off the machine for a minute, i forgot to run the tests..... Now, idk how bad it could have been but i was scared to hear that! Then when she did, i ended up bleeding everywhere, because she forgot to clamp..... Then the machine went nuts again, something to do with the transducers... (no clue lol) ..  Im thankful nothing bad happened, but couldnt it have? I want to take classes at this point, to learn more!

Last dialysis, tues. I went in, couldnt breathe, weighed in about 3k UNDER my dry weight! I said, ooook because i am trying to lose weight. Then I loook at the machine, they have it down.. to take about 2.5k off. i said um thats not right, i want to take some off, but thats not right, if my dw is 100 and i come in at 98, why the hell are u taking off 2.5? She said, no thats right... Oooook. So i get off, i feel like my head my explode, but i ran the whole treatment, and weighed... 101.8? how??? totally baffles me. AND i still cant breathe lol

This type of stuff happens alot, and if u mention it to them, they get offensive.... Does it happen to u all? how do u deal, what should i do?

[paul.karen]

I dont do HD but if i did i would MAKE SURE they heard what i was saying and not just nodding at me and saying uh huh.  You know your body better then any of those nurses.  And we are all individuals who are very differnt then everyone else.
Ask questions learn all you can about the machine they are using and if you think they are trying to take to much UF off tell them and make sure they listen.  Most nurses techs are likely use to elder patients who ask no questions. 

If they are tring to take to much off and you know you wont feel well.  Put your foot down.  I know i would.

[RightSide]

GothicCloveMonkey,

The Fresenius 2008K machines that my dialysis center uses, have their own internal diagnostic tests which run during the dialysis treatment.  If they detect anything abnormal, they will shut down the treatment (stop the pump) and sound the alarm.

Of course, the machine cannot tell if the dialysis nurse is giving you the right doses of the right meds in the dialysate line.  That tragic case in Texas last year should serve as a warning to us all:  NEVER allow anyone to inject you with anything, without asking what it is first.  I always ask whenever I don't recognize it by heart already.

[Riki]

When I went in today, I was up by about 3kgs, but they still asked me what I thought they should take off.  I know that more than 3, and I'll most likely end up on the floor when I do the standing bp at the end of the treatment.  Between the 2 of us (me and the nurse) we settled on 2.8kgs. I felt fine leaving, and I feel good now, and I only left .3kgs over my dry weight.

[RichardMEL]

This baffles me a bit.

Does your unit have an independent check in place? For my 4+ years on D this has been SOP at our unit. Nurse X puts you on, does the calcs etc (with me we agree on the numbers - and I try not to laugh when this one nurse has to get out her calculator to figure out that 80.5-78.5=2  ) anyway then later, usually within the first 30 minutes, nurse Y (always a different set of eyes) will come along, check the connections, double check the calculations(most of the time they bother to check that the dry weight and my wet weight are written correctly and that what should be taken off corresponds with what the machine is set at). They also check the correct bath is setup, the heparin pump settings, etc.

It's actually pretty rare that something is messed up (and of course I check all the settings myself when they are done for my own peace of mind).

I find that system works well to weed out any human errors in terms of configuring the machine and all that kind of thing.

And on the 2008 and 4008 machines we use, the machines run all the diagnostics as part of the rinse cycle that they use before a new patient is put on....

[gothiclovemonkey]

what happened in tx?

I get irritated when they dont listen to me.... i tell them my concerns and they right me off or try to make me feel bad for questioning them

[jbeany]

Texas was a psycho nurse injecting patients with bleach through the D machine lines.

If you get an unexpected reading on the scale, take another weight.  I usually took two every time.  If they are close, take an average - far apart, do it a third time!  Digital scales are touchy beasts.

The best protection against human error screw-ups is learn everything you can about how your machine runs.  Then you can see if it's hooked up right, and if the settings are right and if the bottles contain your prescription for K, etc.  At a bare minimum, calculate your own dry weight/fluid goal and make sure they haven't typoed that into something crash-inducing.  You can, usually, train the nurses at your center to listen to you when you set your own fluid goals - but it takes an effort on your part to get them to see that you care and that you know what you are talking about.  If you are really lucky, you can find a helpful nurse or tech willing to teach you what you need to know.  Otherwise, get the name, model number, etc. from your machine, and figure it out online.  Learn the steps, pay attention, and call them on it when they do it out of order.  You can be nice about it - but firm.  "How come you are doing it xxx way when every other nurse has done yyyy?" or "I thought this was supposed to be set to xxxxx.  Why is it different now?"  Be polite and persistent.  They don't suffer if they screw it up- you do!

I used to have the links, but it's been a long time since I've needed them.  There was a website named something like "kidney school" that gave a lot of lessons on what the lab work meant.  I think they had sections on how the machines worked as well.  At any rate, someone has posted that info online somewhere. 

You took a class to keep you safe and learn skills when you got your driver's license.  You didn't figure everyone else was going to look out for you on the road.  Your life is at risk with D, too.  You can't control the other drivers or the nurses, so you have to learn "defensive driving" for both cases.

[greg10]

..There was a website named something like "kidney school" that gave a lot of lessons on what the lab work meant.  I think they had sections on how the machines worked as well.  At any rate, someone has posted that info online somewhere. ..

http://www.kidneyschool.org/m10/9/
"Your goal weight without excess water is called dry weight. One way to find dry weight is to take off so much water that you get low blood pressure and cramps, and then back off from there. This is not recommended, but there is no practical, clinical way to assess dry weight. It is always trial and error.

As someone with kidney failure, it's up to you to tell your care team if you believe you have gained fat or muscle, so your dry weight can be adjusted:"

[natnnnat]

Kidneyschool.  Well how about that.  How fabulous!

[ChickenLittle56]

There is another to keep in mind and that is to take the rinse back in account when you are trying to set a goal. The PCT tell me .400 kilo of saline is used when starting you up and returning your blood  There were many times my weight ended higher than I wanted when I tell the PCT how much to take set on the machine and I don't add the .400. The startup and rinse back amount could vary on the technician,

[Bruno]

I always weigh myself separately at home before I go to the clinic.and work out what I want to lose in the session. I have to be careful because I'm there 3 successive days and more often than not we are talking about less than 3 kgs...even less. I am also keen on loosing not more than 400 ml per hour...sometimes less. I then discuss my goal with the nurse and usually we agree. If we disagree it is usually to a lower figure than mine...never over. The reason for all this? I want to get out of the centre and do home HD and if that is to happen I need to learn the machine.
To answer another part of your question, I asked my nephrologist why the varying results when we got close to our daily goal (like you and weighed myself at the end of a session and thought "How did that weight happen?") and she said that last 500ml is always going to be difficult. A bit of 'by guess and by gosh' (my words, not hers).
From all this I deduce that you are better off undershooting your goal as a general rule.
Having said all that I need to tell you that my biggest and most consistent problem during dialysis is low blood pressure. Which is bloody ironic when I have taken heaps of rotten tablets for HIGH bp for most of my life.

[RichardMEL]

Jbeany - GREAT POST!  Couldn't agree more.

I do all that as a matter of course. It's all second nature now. Luckily my nurses all know that I understand what's going on and that if I make a request to change something I usually have a good reason(and I tell them anyway) and I don't think they've ever said "no" to a reasonable request. If they disagree with some reason than we usually talk it through and reach a consensus. That's rare though. I believe I am trusted enough after all these years that I do have a bit of an idea what I'm doing.

Luckily when I started D I did have a nurse take me under her wing and explained a lot of stuff to me, encouraged me to understand more about my labs the values, stuff like UF profiles and how they could help etc. Understanding really IS power. I now feel confident that when I go into a treatment I can tell what's going on with my machine and know if anything obvious is set wrong. And from time to time yes I have seen the odd error. Once they set me for 4 hours instead of 5. I really wrestled with not telling them about that one!! However sanity ensured because I figured the checker would pick it up anyway. Mostly though they are spot on.

Definitely good words of advice.

[Restorer]

At both centers I've done hemo, two techs or nurses had to sign off on a patient's settings. Unfortunately, at my last center, the second tech usually signed off without looking at the machine or settings. At my current unit (which is much smaller, and better - they keep reminding me they're a "top ten" center, though I don't know top ten of what ) the staff-to-patient ratio is higher, and since I have a catheter, I'm always connected by a nurse, while the tech in charge of my machine sets things up, and the settings always get double-checked. The only human error I've seen here is that one time they forgot to draw after-D labs before the rinseback. 

[RightSide]

At my dialysis center, they still write down the numbers off the Fresenius 2008K machine readout on a paper form--and then they walk over to the computer and enter the numbers from the form into their database manually.  That, of course, invites all sorts of coding errors.  As well as being unnecessarily time consuming.

At my dialysis session today, I was told by a nurse that my center is planning to integrate the dialysis machines to the computer directly (Wi-Fi probably), so that the readouts from the machines will be electronically fed into the computer's database automatically. 

How is it done at your center?  Do the techs and nurses still write down the numbers off the dialysis machine readout by hand and then enter them into the computer later--or are the machines integrated electronically?

[gothiclovemonkey]

The one i go to now, does it by hand, writes down throughout the treatment, on a clip board, then i dont know what they do.
the old one i went to, they have 1 computer per 2 machines, and they put info straight into the computer.

[ChickenLittle56]

I miss the old ways of putting it on paper because I can reach over grab the paper and take a look at whats going on with my machine. Now with the computers I no idea.

[RichardMEL]

In our unit it goes like this. Paitents have folders. In them is, if you will, a potted history of dialysis - the initial induction papers, all nursing notes, current list of meds & doses(supposed to be kept up to date), doctors notes and instructions, if any (when I go to see the neph, the primary nurse writes a little "summary" letter, he reviews and writes what he thinks back, including any changes he wants etc - he takes a copy and the original stays in the folder), and treatment notes for the past few sessions.

Recently they have also brought in a new system where they scan in the treatment notes into the system which I think goes into your medical records as a permanent record. We have one treatment page / session where all the stuff is recorded - eg: dry weight target, initial weight, BP, calculated UF target, any profile, what meds are due(if any) and the hourly obs and any other notes (eg: "patient cramped. patient drank vodka and yelled at TV" etc).

[gothiclovemonkey]

patient drank vodka and yelled at TV" etc).

 

[Riki]

In our unit it goes like this. Paitents have folders. In them is, if you will, a potted history of dialysis - the initial induction papers, all nursing notes, current list of meds & doses(supposed to be kept up to date), doctors notes and instructions, if any (when I go to see the neph, the primary nurse writes a little "summary" letter, he reviews and writes what he thinks back, including any changes he wants etc - he takes a copy and the original stays in the folder), and treatment notes for the past few sessions.

Recently they have also brought in a new system where they scan in the treatment notes into the system which I think goes into your medical records as a permanent record. We have one treatment page / session where all the stuff is recorded - eg: dry weight target, initial weight, BP, calculated UF target, any profile, what meds are due(if any) and the hourly obs and any other notes (eg: "patient cramped. patient drank vodka and yelled at TV" etc).

We have the same type of system.  I'm not sure what goes into the computer, but everything is written out and kept in our chart, which is pretty much just a binder with all the info in it. I know that any bloodwork done comes back on the computer.

I'm also not sure how many patients drink vodka and yell at the tv during treatments either, though I"m not there on Saturdays, so who knows?

[RichardMEL]

Yesterday it was Ouzo. One  of the greek patients got upset that I had vodka (note, it was a patient, not the nurses?!) so ti honour his request, and honour him, I brought Ouzo for yesterday's game. Ironically he was put in the isolation room, and I wasn't, but he was yelling harder than all the rest of us (and no he didn't drink!!) 

I'm done with alcohol at dialysis for now (until next football season anyway) - lest anyone think I've got a problem with the bottle or something

oh yeah we got birthday cake yesterday - something with whipped cream and chocolate. I bought coffees to go with it. YUMMY!!!!!!!!!!!!!!!!!!!!

oh yeah this doesn't have much to do with human error... well.. umm... how about this.. I added 100 mil to my UF target to account for the ouzo drinkie, and 200 for the coffee, and I came off 150 under target... thus.. human error!!! 

[kitkatz]

The ass kicking starts as soon as a mistake is noticed by me. I am on them like flies on honey. When they know you are watching them, they take real good care of you.

[KICKSTART]

RM ...i want to come to your unit ! You had cake , you bought coffees , you drink vodka. Blimey , if we brought booze in , we would be thrown out. There is no way we are allowed coffee , let alone anywhere to get it ! and CAKE .. We get during dialysis the luxury of a small plastic cup of tea (i think its tea , but im not sure because if the colour ! and (oh yes theres more )..the luxury of either 2 ginger biscuits or 2 digestives )

[RichardMEL]

Sorry KS!! I don't mean to make you jealous. I'll clarify a couple of things.

1. The cake was brought in by a patient - it's his birthday on Monday. It's kind of a weird tradition in our unit - if it's your birthday - bring cake!!!  (the staff sure clean up on that one!!!)

2. Of course I'm not supposed to have the booze. Let's just say it's a special occasion (football grand final). I think the thing is that our unit staff are relaxed about such things. I think they know that dialysis is difficult enough for all concerned. If we want a little something extra, and aren't too disruptive or over the top or something.. then why not. I'm sure if I drank every section I'd be booted out too!!! I've been there four years, and they know I'm (normally) responsible and all that, and well I think it amused some of them that I actually DID IT!  One of the nurses got all "tsk tsk" at me and went on about how I shouldn't have it blah blah blah. Well you know if they were serious about it all they had to do is take the bottle away from my desk - I can't exactly run after them and grab it back can I? I mean I had the bottle there quite in the open, so I wasn't lying about it or anything. In the end a bit of fun. If I made a habit of it though I'm sure they'd have some serious words... but it's not like that.. just a bit of fun.

3. Normally we just get the plastic tea too. We do get a "lunch" as well... well if you call these tiny horrible triangle sandwiches a meal... ugh.. but hey it's food. A few of us bring in extras to munch on. The main PSA we have who makes the tea/coffee is a really wonderful lady (she's from Argentina and claimed she was a Flight Attendant in the 1970's)... she makes the most awesome tea ever. Not sure how she does it, but it's always wonderful when she makes it for me

4. The coffee's are my donation to make everyone a bit happier. One of the nurses will collect $$ from me and go to the cafe and bring back everyone who wants a latte or hot chocolate or whatever. I don't do it all the time, but sometimes it's just nice to put up some money and give everyone (staff and patients) something a little nice. It depends which boss is working if it happens of course, but I get on pretty well with one of the main ones, and hey she gets coffee out of it, so why not?

Incidently, and this is a funny, she was calling out what she wanted "Flat White, extra Hot" and I piped up and said "Awww isn't that nice of you to describe me like that!!"  I was quite proud of that one!!

It's little things like this that make life a little easier in an environment that really isn't fun for anyone... I do my bit (a bit of a clown as you all know!) and the main thing is we all get on well.

[Stoday]

We get during dialysis the luxury of a small plastic cup of tea

My unit must be first class — I get TWO small plastic cups of tea.

But they take them off you again by setting your target up 

[natnnnat]

Let's just say it's a special occasion (football grand final).

To provide further context for this business of the football for Richard, I will add:  Australia is obsessed with certain sports.  One is a particular horse race, which is good because the entire nation has a boozy afternoon at work watching telly and betting on the outcome.  Next are various kinds of football, by which I mean the game played with the ball with two pointy ends.  In Victoria, Richard's location, they are completely and utterly obsessed with that code he carries on about.  No one else in the country cares much, but in Melbourne it would be quite reasonable to expect special favours on the day when your team is in the grand final. 

Pity they rolled over.