Patient safety issues in CKD: core curriculum 2015.

Health professionals generally intend to provide effective, safe care and do no harm. Since the Institute of Medicine’s 1999 report To Err is Human brought attention to the overwhelming number of preventable medical errors in hospitals, it has become apparent that numerous threats to patient safety exist. The report estimates that between 44,000 and 98,000 patients die yearly from preventable medical errors. This staggering statistic does not capture patients otherwise harmed, or those who had “near miss” events. Understanding the vulnerabilities of specific patient populations can help providers better protect these patients. Patients with chronic kidney disease (CKD) are at an inherently increased risk for adverse safety events. Patients with CKD, whether presenting with reduced glomerular filtration rate (GFR) or with kidney damage but preserved function, are at risk of complications from nephrotoxic medications and inappropriate drug dosing. These patients have complications like anemia, hypervolemia, and electrolyte imbalances, along with comorbid conditions like diabetes, hypertension, and heart disease, which prompt frequent health care encounters, thereby increasing patients’ risk for adverse events. Moreover, adverse safety events in CKD have the potential to accelerate loss of kidney function and may increase the risk of end stage renal disease (ESRD) beyond what is expected from the disease’s natural history. Defining adverse safety events in CKD requires a nomenclature that incorporates various dimensions of safety as they relate to the disease. Box 1 distinguishes between adverse events and safety hazards. The former represent harmful clinical occurrences that are consequences of well-intentioned medical care (as opposed to the natural disease process). Safety hazards include ill-advised practices, omissions, or poorly monitored care that raise the risk of an untoward complication. Box 1 Safety nomenclature for CKD care Adverse Events Definition: harm to patients which results from medical care Subtypes ◦ Patient-reported safety incidents (falls, bleeding, hypoglycemia) ◦ Safety findings (hypoglycemia, hyperkalemia, orthostasis) ◦ Condition-dependent safety events (acute kidney injury after surgery, congestive heart failure after IV fluids) Safety Hazards Definition: clinical practices with the potential to lead to unintended patient harm Subtypes ◦ Errors of commission ▪ Definition: harm results from an action taken ▪ Examples: use of known nephrotoxins, improperly-dosed medications ◦ Errors of omission ▪ Definition: failure to provide care results in harm ▪ Example: use of an ACE inhibitor ◦ Use of therapies that require monitoring to mitigate harm ▪ Examples: diuretic, RAAS blocker, erythropoetic-stimulating agent, digoxin Near Miss Definition: event that did not cause patient harm, but only because of chance View it in a separate window Abbreviations: CKD, chronic kidney disease; IV, intravenous; ACE, angiotensin-converting enzyme; RAAS, renin-angiotensin-aldosterone system Compounding its enhanced risk for adverse safety events, CKD is often under-recognized by providers, particularly in elderly patients who may have a seemingly normal serum creatinine but significantly reduced GFR. Delayed recognition (or under-appreciation) of reduced GFR may postpone the initiation of therapies that slow CKD progression, as well as interfere with proper dosing of medications and avoidance of nephrotoxins. The National Kidney Disease Education Program (NKDEP) was launched in 2003 to raise awareness among primary care providers and high risk patients, and advocated for automatic reporting of estimated GFR (eGFR) along with serum creatinine in laboratory reports. Despite this effort, inappropriate medication dosing and nephrotoxic medication prescription among CKD patients persists. In this Core Curriculum, we review common complications of CKD management and medical interventions that pose significant threats to patient safety. Although dialysis patients and transplant recipients face unique health care dangers, we will focus on those issues specific to non-dialysis-dependent CKD.