I was just going along and doing my civic duty. We decided at DialysisEthics it would be a good idea to put state_inspections_and_lawsuits on the website as a way for staff and those on dialysis to see what can go wrong at a clinic. Things were going along as I would have expected, when I came upon Colorado’s El Paso county!
If I was davita I would consider giving up on reuse, their TWO incidents in just ONE county sure seemed to upset the state of Colorado and the press (see related articles in inspection reports). Makes me wonder how many incidents go unreported. El Paso sure looked like an epicenter of trouble there for awhile:
Looks like a wise decision! I got my daughter off ten years ago when she was in a fresenius clinic, haven’t seen much of a reason to regret it. I still think it was a great day when fresenius stopped doing reuse.
At this point, reuse is practiced less frequently, although with bundling starting in January, there is a possibility that clinics will go back to it.
One of the things that should prevent one patient from getting another patient’s dialyzer is if the dialyzer is marked with the patient’s name and dialyzer checks are done as they’re supposed to be. At least two people – one of which should be the patient if competent and vision is good enough – are supposed to check the dialyzer to be sure the patient identifier is correct before dialysis is started. If patients have similar names, the facility is supposed to have safeguards to prevent a patient from getting the wrong dialyzer. Obviously in these cases, something was missed and patients were needlessly exposed to infections.
The way I look at it, these clinics have been doing reuse for a long time and they STILL can’t account for human error! Have to wonder how many incidents go unreported. This was two incidents in ONE county!
Using the wrong dialyzer is quite a bit like hanging the wrong bag of blood. Neither event should EVER happen. Clinics should have zero tolerance for this mistake, which is 100% preventable. Like blood, two different people need to verify that the right reused dialyzer is being used. As Beth points out, one of them should be the dialyzor, if that’s possible (if the person can see, and can read, and can understand). Of course at home, this isn’t a problem.
Thanks, Plugger! I hadn’t seen either of these. We’ll be revising the Core Curriculum for the Dialysis Technician next year, and there is a module on dialyzer reprocessing. I’ll make sure that we do an up-to-date lit search for it.
