Right Patient, Right Prescription, Every Time: A Quality Improvement Project for Two-Person Time-Out in Dialysis

Abstract

Background: Patients diagnosed with end-stage renal disease (ESRD) receiving in-center hemodialysis (ICHD) three times a week are at risk for unintentional harm from human error when programming dialysis machines. Accurate dialysis is vital for patient safety, improved health outcomes, decreased adverse events and hospitalizations, and lowered healthcare costs. Evidence supports the use of standardized time-out procedures to mitigate medical errors, ensuring the accuracy of the patient and procedure, and this practice is commonly performed before invasive procedures in other clinical settings.

Local Problem: Current policy within a dialysis company states that the licensed nurse will verify the dialysis prescription within the first hour of treatment initiation. A one-hour window poses a risk of 25% or more of a patient’s dialysis being delivered with the wrong prescription. The purpose of this project was to standardize a two-person timeout procedure before each dialysis treatment with the aim of reducing dialysis prescription entry errors by 50%.

Methods: The Model for Improvement (MFI) was the guiding framework for this project. A pre-hemodialysis timeout checklist was implemented utilizing PDSA (plan-do-study-act) cycles and a process map. Error rates were measured pre- and post-implementation; the checklist use rate was measured post-implementation.

Intervention: A two-person timeout procedure was completed before the start of every dialysis treatment, guided by a pre-hemodialysis checklist and process map.

Results: The implementation of the checklist reduced machine set-up errors by 53% across 543 total treatments. Increased checklist compliance resulted in decreased errors.

Conclusion: Implementing a two-person timeout, using a pre-hemodialysis checklist, before initiating dialysis treatments in the ICHD setting resulted in a 53% reduction in machine setup errors, exceeding the project's aim. The integration of a timeout checklist into the electronic medical record (EMR) is recommended to enhance usability and sustainability, thereby improving patient safety and the delivery of adequate dialysis.