Dialysis guidance
This guidance has been produced in collaboration with the UK Kidney Patient Safety Committee (KPSC), to summarise known safety issues with dialysis and continuous renal replacement therapy (CRRT) and describe what to do to minimise or prevent serious injury.
Latest change: Updated the dialysis guidance following engagement with HSIB relating to their investigation: ‘Safety risks associated with central venous catheters (CVCs) used for haemodialysis treatment’.
AI Summary
The Medicines and Healthcare products Regulatory Agency (MHRA), in collaboration with the UK Kidney Patient Safety Committee, has issued updated safety guidance for renal replacement therapy (RRT). This guidance addresses critical safety risks associated with haemodialysis, peritoneal dialysis, and continuous renal replacement therapy. While the document does not specify particular inspection dates, it serves as a comprehensive update to previous safety protocols within the UK regulatory framework. Key issues identified include the use of incorrect disinfectants due to similar packaging, potential air embolisms from improper tubing priming, and the life-threatening risk of venous needle dislodgment. A major concern highlighted is the repeated overriding of machine alarms without investigation and incorrect data entry for fluid management. Furthermore, the guidance warns of medication toxicity, specifically regarding opioids, in patients with impaired kidney function. Required actions include implementing rigorous competency-based training for both staff and home-dialysis patients, performing manual pre-use equipment checks rather than relying solely on automated alarms, and strictly adhering to manufacturer instructions. Healthcare providers must ensure accurate patient weight measurements to prevent fluid overload and are encouraged to report all adverse incidents through the Yellow Card scheme to maintain safety standards.
The full document, source attachments, and change history are available on KeyPedia. Sign in to view.