Topic: Questions to participants in a semi-structured interview
Order
Research question: what factors compromise patient safety for adults undergoing hemodialysis from the nursing perspective in HD unit in Saudi? Aim of the study: To explore the perceptions of nursing staffs towards patient safety for adults undergoing hemodialysis in HD unit in Saudi. To understand what compromises patient safety for adults undergoing hemodialysis from the nursing perspective in HD unit in Saudi.
I need 20 question to ask haemodialysis nurses regarding their beliefs, attitude and experience toward factors compromising patient safety.
factors compromise patient safety as below: 1- medication 2-communication 3- patient fall 4- failure to follow policies and protocols 5-ability of nurses to detect errors 6-machine errors 7-infection(hand hygiene- machine-access av fistual-prevention) 8-hypovolemia(hypotension-catheter leakage-access infiltration).
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 41 Error Recovery by Dialysis Technicians M edical errors are a major problem in healthcare deliv-ery. Over a decade ago, the Institute of Medicine (IOM) (2000) estimated medical error-relat-ed deaths exceed the combined num-ber of deaths in America attributed to motor vehicle accidents, breast can-cer, and AIDS, and estimated that the non-fatal morbidity from medical errors injures a million patients annu-ally. The complexity of healthcare practice has been proposed as one of the major barriers to taming this problem (Amalberti, Auroy, Berwick, & Barach, 2005; Leape & Berwick, 2005). The complex nature of detect-ing and recovering from errors in health care poses challenges for healthcare professionals. William E. Wilkinson Lee A. Cauble Vimla L. Patel Continuing Nursing Education William E. Wilkinson, DrPH, JD, RN, CNN, is Risk Manager, DCI Arizona, Tucson, AZ, and Researcher, Arizona State University, Department of Biomedical Informatics at Mayo Clinic Campus, Scottsdale, AZ. The author may be contacted direct-ly via e-mail at wwilkinsonaz@gmail.com Lee A. Cauble, BSN, RN, is Nurse Manager, DCI Desert Dialysis Center, Tucson, AZ. Vimla L. Patel, PhD, DSc, is Senior Research Scientist and Director, Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, NY. Acknowledgment: This research was supported by an award from the James S. McDonnell Foundation (JSMF 220020152) to Vimla L. Patel. Special thanks to Lawrence Brauer, Amy Sussman, Machaiah Madhrira, Howard Lien, Janet Umstead-Tobias, Julie Lightner, Bradford Guidry, Laura Davis, Rachel Buck, Stephen Mistler and Diana Petitti at various stages in this study. Statement of Disclosure: The authors reported no actual or potential conflict of interest in rela-tion to this continuing nursing education activity. Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 51. This offering for 1.4 contact hours is provided by the American Nephrology Nurses Association (ANNA). American Nephrology Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation. ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910. This CNE article meets the Nephrology Nursing Certification Commissions (NNCCs) continu-ing nursing education requirements for certification and recertification. Copyright 2014 American Nephrology Nurses Association Wilkinson, W.E., Cauble, L.A., & Patel, V.L. (2014). Error recovery by dialysis techni-cians. Nephrology Nursing Journal, 41(1), 41-50. Retrieved from http://www.pro libraries.com/anna/?select=session&sessionID=2968 Experts are believed to make fewer errors than novices. Researchers in other domains have shown that experts not only make less errors, they also detect and recover from these errors better than non-experts. To investigate this phenomenon among dialysis techni-cians working in hemodialysis, we evaluated the ability of dialysis technicians to detect and recover from healthcare errors. Two clinical cases with embedded errors were creat-ed by an expert nephrology nurse. Twenty-four dialysis technician subjects read the cases aloud and then answered a set of related questions. Subjects error detection and recov-ery responses were scored against the clinical cases. We found that there was no signifi-cant difference between the ability of expert and non-expert dialysis technicians to detect errors. However, expert dialysis technicians recovered from significantly more healthcare errors than less experienced, non-expert dialysis technicians. This has implications for training dialysis technicians in better error detection and recovery strategies. Key Words: Patient safety, hemodialysis, dialysis technician, medication errors, quality improvement. Goal To study the detection and recovery of healthcare errors of dialysis technicians as a method to improve patient safety. Objectives 1. Discuss the concept of error recovery and its role in patient safety. 2. Discuss the ability of expert and non-expert hemodialysis technicians to detect and recover from errors based on the results of this study. 3. Utilize this research to improve future technician education and continuing education programs. Hemodialysis is a complex spe-cialty area that requires focused train-ing and experience. Dialysis techni-cians provide direct care services to patients with end stage renal disease (ESRD) and are cost-effective, nursing care extenders under direct nursing supervision. Dialysis technicians are required to learn specialty skills and undergo extensive on-the-job training because during treatment, patients can suffer severe fluid and electrolyte im -balances, or can develop cardiac, pul-monary, and other fatal complica-tions. Dialysis technicians provide ad -ditional personnel required nationally Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 42 Error Recovery by Dialysis Technicians to meet dialysis treatment de mands and reduce costs (Fields, 2010; Kirby & Garfink, 1991; Wolfe, 2011). There are more dialysis technicians than nurses and doctors combined who work in hemodialysis (Medical Edu -cation Institute, Inc., 2012). Certification is required to work beyond 18 months in the field (Centers for Medicare and Medicaid Services [CMS], 2008). Arizona pass -ed legislation requiring technicians to be certified within two years of em -ployment. As of October 14, 2008, all Arizona patient care technicians (PCTs) are required to become certi-fied within 18 months of employment as a PCT (Arizona State Legis lature, 2008; Levy, 2008). Not all certifica-tion examinations approv ed by states are nationally recognized, and certifi-cation may only be valid within the state in which it is administered. Prior to 2008, training of PCTs varied from facility to facility, and even sometimes within large organi-zations lacked standardization. Under the 2008 CMS Conditions for Parti -cipation, V694 specifies the training curriculum that must be included for all PCTs (CMS, 2008). The training program must include the following subjects: principles of dialysis; care of patients with kidney failure, including interpersonal skills; dialysis proce-dures and documentation, including initiation, proper cannulation tech-niques, monitoring, and termination of dialysis; possible complications of dialysis; water treatment and dialy -sate preparation; infection control; safety; and dialyzer reprocessing, if applicable. These eight areas have been the foundation of the training for all PCTs at DCI Desert Dialysis since 1985. In addition to the didactic portion of the training, PCTs undergo a preceptor-led 8 to 12 weeks of clini-cal training. The preceptors are PCTs with two or more years of experience supervised by the nurse educator. They have received training in adult learning and demonstrated a willing-ness and ability to be leaders in the clinic. Since 2003, the preceptors have also been required to be certi-fied by a national certification pro-gram. The Certified Clinical Hemo -dialysis Technician (CCHT) adminis-tered by the Nephrology Nursing Certification Commission (NNCC) is the examination all have chosen at this facility. Though many, but not all, dialysis technicians have substantial training, accidental deaths of patients on hemodialysis have occurred from dial-ysis care errors made by dialysis tech-nicians. In 2008, a 71-year-old female patient on hemodialysis died because a reused dialyzer still filled with steri-lant was connected to the patient with-out first rinsing out the sterilant; car-diac arrest and brain in jury occurred (Moore, 2008). In 2005, a dialysis tech-nician did not properly tape a female patients fistula access needle, which was then covered up with a blanket. Blood pooled underneath the patient, and she exsanguinated (Fields, 2010). In 1988, a 68-year-old patient on hemodialysis died because a dialysis technician in a New Jersey clinic gave the patient lidocaine, an anesthetic, instead of mannitol, used to increase blood pressure (Palley, 1988). Data collected by the Pennsylvania Patient Safety Authority, a state healthcare injury tracking system that includes hemodialysis-related data, illustrates the kind and frequency of errors that occur in the care of patients on hemodialysis. One recent report by the Pennsylvania Patient Safety Authority (2010) presented an analysis of dialysis errors found in Pennsylvania over a one-year period: From November 12, 2008, through October 31, 2009, Pennsylvania healthcare facilities submitted 526 event reports involving hemodialysis administration to the Pennsylvania Patient Safety Authority. Medication errors were the most common type event submitted, representing almost 29% (n = 150) of all hemodialysis-related events. Other hemodialysis administration events involved failure to follow policy or protocol, such as treatment set-up procedures (12.9%), needle disconnection and needle infil-tration (6.1% for each category), and falls (5.9%) (p. 87). Preventing and mitigating care-giving errors to promote the safety of patients on dialysis is a vital and inte-gral component of nephrology nurs-ing practice (Ulrich, 2004, 2007, 2008). Without a doubt, our role as patient advocates calls on us to do our best to ensure patient safety (Ulrich, 2008, p. 237). The few studies that have looked at clinician error in health care have generally focused on physicians and not on front-line pro -viders, such as nurses, healthcare aides, dialysis technicians, or medical assistants (Rothschild et al., 2006). Statement of the Problem And Theoretical Framework Dialysis technicians are the larg -est single category of hemodialysis healthcare providers in the industry. The large number of dialysis techni-cians substantiates the need to study those healthcare errors related to hemodialysis, which could be attrib-utable to dialysis technicians, to im -prove patient safety. The literature shows that 10 years of experience is required to establish competence to become an expert (Leprohon & Patel, 1995; Patel & Kaufman, 2006; Wilkinson, Cauble, & Patel, 2011). Experts are believed to make fewer errors than non-experts, yet current research suggests experts still make countless errors (Amalberti, 2001; Patel & Cohen, 2008; Patel et al., 2010; Reason, 2004). Experts have also been found to detect and recover from these errors better than non-experts (Nyssen & Blavier, 2006). Experts make errors, but surpass non-experts theoretically with superior error management strategies that help them detect and recover from them more effectively (Amalberti et al., 2005; Armitage, 2009; Patel & Cohen, 2008; Rasmussen, 2003; Reason, 1990). Patel and Cohen (2008) outlined three conceptual stages to describe error recovery: near miss , miss, and adverse event due to an error in evolution. A near miss happens when the regular routine is violated, but the error con-dition can be terminated prior to the happening of unintended conse- Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 43 quences. For example, a dialysis tech-nician draws up a heparin loading dose of 2000 units of 1000 units/mL concentration heparin and discovers before the heparin is given to the patient that the heparin loading dose should be 4000 units of 1000 units/ mL concentration heparin. The dialy-sis technician then redraws 4000 units of the heparin to administer to the patient who then receives the correct loading dose of heparin (Patel & Cohen, 2008; Patel et al., 2010). A miss occurs when the erroneous action is completed for an error to potentially create an adverse outcome yet none has happened. An example of a miss category of error in evolu-tion occurs when a dialysis technician connects a patient to a 2K dialysate and discovers immediately after the patient is connected to the dialysis machine but before the patient is dia-lyzed that the order is for a 4K dialysate. The dialysis technician then disconnects the 2K dialysate and reconnects the dialysis machine to a 4K dialysate so the pa tient is not dia-lyzed with the wrong potassium con-centration dialysate for the dialysis time duration ordered (Patel & Cohen, 2008; Patel et al., 2010). An adverse event due to error in evolution happens when an unwanted conse-quence occurs. For example, an adverse event occurs when a patients fistula access lines are reversed, the treatment is completed, and the patients blood is re-circulated so the patient needs to be re-dialyzed. If an error in evolution is detected and recovered at the near-miss stage, it can be stopped from developing into an adverse event. People generate mental schemata in the error recovery process. Sche -mata are mental tools that assist indi-viduals to cognitively manage situa-tions, events, and action sequences. The reader is referred to Ericsson and Simon (1980) and to Patel et al. (2008) for additional information on the con-cept of schemata and the use of sche -mata in error recovery. Schemata help filter out irrelevant information, leaving the relevant information to be useful for enhancing the effectiveness and efficiency of an individuals deci-sion-making process. Dialysis techni-cians form their internal schemata from their own education, training, and past experiences regarding com-plex dialysis treatment to provide the care they give to their patients (Leprohon & Patel, 1995). Dialysis technicians use their internal schema-ta to prioritize and manage errors they are able to detect and then re -cover (Armitage, 2009; Janicik & Larrick, 2005; Patel et al., 2010). The purpose of this study was to explore the ability of dialysis techni-cians to detect and recover from healthcare errors covertly embedded in dialysis-specific clinical care scenar-ios. We hypothesized that expert dialy-sis technician subjects (defined in this study as those certified dialysis techni-cians with 10 or more years of dialysis experience) would detect and recover from more errors than the lesser expe-rienced, non-expert dialysis technician subjects (defined in this study as those with less than 10 years of dialysis expe-rience whether certified as dialysis technicians or not) as found in other technical and professional fields. This study was part of a larger study that looked at the performance on error detection and correction by nurses and dialysis technicians (Wilkinson et al., 2011). One part of this study with nurs-es showed performance with procedu-rally based error detection and recov-ery was significantly higher as a func-tion of expertise (p < 0.05). More experienc ed nurses performed better than the less-experienced nurses when detecting and recovering procedurally bas ed errors. However, no differences were found between these groups for knowledge-based errors (Wilkinson et al., 2011). Study Design and Methods We conducted an empirical study to determine if dialysis technicians were able to detect and recover from the number of embedded errors with-in two clinical case scenarios. The clinical sites at which the study occurred were part of a single nation-al dialysis care corporation. All dialy-sis technicians from five clinical dialy-sis settings in Southern Arizona were invited to participate in the investiga-tion from June through August 2009. Human subjects approval was ob -tained to conduct the research. Four of the clinical locations were outpa-tient dialysis clinics, and one site was an inpatient hospital setting. The five sites were supervised by a single administrator, and the staff rotated working in other sites occasionally to meet patient coverage and staff vaca-tion needs. The training of dialysis technicians at the study locations was overseen by one in-house masters-prepared nurse educator with three de cades of nephrology nursing expe-rience. Dialysis technician training included instruction with a core cur-riculum established by the national dialysis corporations education de -partment and a concurrent 8 to 12-week, preceptor-led, on-the-job train-ing and evaluation component. Clinical Case Scenarios The clinical case scenarios were developed under the direction of an expert nephrology nurse who has worked in hemodialysis for 34 years and who was a nurse manager for one of the chronic-care hemodialysis clin-ics in Southern Arizona. The two clin-ical scenarios reflected a composite of realistic chronic care for patients on hemodialysis and treatment events that have happened or could happen with any patient who receives hemo -dialysis treatments. Two other neph -rology nurses experienced in hemo -dialysis reviewed and validated the clinical scenarios. The clinical cases with the embedded errors in bold are shown in Tables 1 and 2. Clinical Case 1: Error Detection and Recovery There were five procedural er -rors. Procedural errors are defined as errors made while performing dialysis care that are derived from routine schema-driven and protocol-driven activities that are typically performed by dialysis technicians. Procedural errors incorporate both categories Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 44 Error Recovery by Dialysis Technicians described in the human error litera-ture as rule-based errors (managed by rules and procedures that may be wrong or recalled inaccurately) and skill-based errors (using mental mod-els of tasks automatically) (Leprohon & Patel, 1995; Patel et al., 2010). There were also knowledge-based errors embedded within the two cases. The knowledge-based error information category required dialy-sis-specific nursing domain knowl-edge that would not be possessed by non-licensed nursing trained person-nel. Consequently, though present in the study cases, the knowledge-based healthcare errors in the two clinical cases, which were used additionally to study nurses working in dialysis in another study, were ignored for the dialysis technician research compo-nent presented herein (Wilkinson et al., 2011). Three procedural errors involved programming incorrect computer set-tings on the dialysis machine. Proce -dural Error 4, an incorrect potassium concentration, was the most critical to miss. Failure to detect and correct the other errors could cause problems; however, they were not necessarily life-threatening. Procedural Error 1: Using the wrong dialysate. The first machine programming error shows the time listed in Clinical Case 1 to be 3.5 hours. The setting programmed into the machine, which should be 3.5 hours as prescribed, is actually 3 hours and 50 minutes. This gives the patient an extra 20 minutes of treat-ment instead of the 3.5 hours as pre-scribed. The 3.5 hours was translated into 3 hours and 50 minutes. The pro-gramming for Procedural Error 12, the time being extended by 20 minutes from 3 hours and 30 minutes to 3 hours and 50 minutes, would not be harmful to the patient under most cir-cumstances. If the amount of fluid removed during the treatment was increased during the extra 20 min-utes, a fragile patient could be affect-ed negatively either during the treat-ment or later at home after the treat-ment. The extra fluid loss could trig-ger electrolyte imbalance and pro-Table 1 Case 1 Text with Embedded Clinical Errors Bolded Julia, a 61-year-old Hispanic woman, presents in triage with a two-year history of ESRD, secondary to diabetes mellitus type II. She has a left UA fistula. There is a thrill and bruit present per palpation and auscultation. Her vital signs are elevated with blood pressure of 174/102, pulse 96, respirations 20. Her temperature is 96.7. She complains of SOB and ankle swelling. Her EDW is 49.4 kg. The patients weight today is 56.1 kg. Breath sounds are diminished bilaterally. She has 3+ edema in BLE. A sys-tolic murmur is audible. Julia is taken back to station 5 for hemodialysis (HD) after being triaged. Her dialyzer is checked for her name. The dialysate bath is 4K, 2.5 Ca. Louise is assigned as her dialysis technician. The dialysis machine is pro-grammed to remove 4.2 kg of fluid over 3.5 hours of HD treatment. The red and blue lines are both plugged into the wall outlets.Louise entered the following machine settings: Flowrate 600, time 3:50, volume 42, heparin stop time 45 min., heparin rate 1500. Dialysis needles are inserted into the fistula with the red line above and blue line below. Two hours into treatment, Julia has received the following med-ications: Epogen ® 4900 units, IV; Venofer ® 100 mg, IV; Zemplar ® 5 mcg; and Calcitriol ® 3 mcg . Julias blood pressure has dropped to 96/48, and she is shouting that both of her feet and legs are cramping. The patient is placed in minimum and given 100 cc of normal saline IV. She improves immediately, and cramping abates for over an hour . She then again complains of severe cramping, and 10 ml of 23.4% saline is given IV.Julia completes her HD treatment, clamps are used to help her blood clot, and she is instructed to return for her next treatment in two days. Source: Wilkinson et al., 2011. Reprinted with permission from the Journal of Patient Safety . Table 2 Case 2 Text with Embedded Clinical Errors Bolded Mason, a 53-year-old African-American male, came in for his usual tri-weekly treatment. He has been on hemodialysis (HD) for two hours and 45 minutes of his 4.25 hours HD treatment run. Norma, Masons HD technician, shouts out, I need help over here now. The charge nurse just left on break. The staff nurse notes that Mason had 4.12 liters of fluid removed so far. The time is 10:46 a.m. The patient is completely non-responsive to verbal questioning. The nurse notices that the pupil in one eye is larger than the other. Attempts to arouse Mason by shaking his shoulder are unsuccessful. A hypertonic is given via his catheter access site. Masons blood pressure is 222/134, and his heart rate is 92 and irregular. It is Saturday and no other nurse is in the office. The charge nurse is across the street in the kitchen on a late break because it has been a busy, hectic morning. The nurse comes back to check on how Mason is responding to the hypertonic solution given to him 13 minutes ago. The time is now 11:15 a.m. Masons condition has not changed. He remains non-responsive, and his body is flaccid. The staff nurse leaves Mason to get the AED. On the way to get the AED, the charge nurse returns from break and the staff nurse tells the charge nurse what has happened. The charge nurse calls 911. Paramedics arrive, and Mason is taken to the nearest hospital emergency room and admitted. Mason died two days later from a stroke he developed while on hemodialysis. Source: Wilkinson et al., 2011. Reprinted with permission from the Journal of Patient Safety . Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 45 duce muscle cramping and fatigue for the patient. Procedural Error 2: The vol-ume of fluid to be removed dur-ing the hemodialysis treatment. The nurse who triaged the patient directed that the dialysis machine be programmed to remove 4.2 kg of fluid (4200 mL of fluid). The error embedded shows that the volume of fluid programmed for removal was 42 kg. It would be deadly to remove 42 kg of fluid from any patient. The dial-ysis machine should catch and not allow an error of that magnitude to occur. Procedural Error 2 was program-ming the machine to remove 42 kg of fluid. The correct setting should have been 4200 mL of fluid to be removed. A setting of 42 kg would obviously be too much (10 times the amount that should have been removed). It would be impossible to remove this amount of fluid. Attempting to remove 42 kg of fluid could cause harm to the patient even part way through the treatment. The harm caused could include electrolyte imbalance, muscle cramping, hypotension, nausea and vomiting, and headache. In the worst case, it could possibly result in a patients death with severe dehydra-tion. Procedural Error 3: The hepa -rin infusion rate per hour pre-scribed for the patients treatment. The rate prescribed is 1500 units per hour. The Braun machine does not accept a rate calculated in the number of heparin units. The machine re -quires programming of 1.5 mL per hour. The rate shown in the scenario is 1500, and it should be 1.5 mL. The procedural error concerns incorrectly cognitively converting heparin units into mL/hour. This may be a Braun machine-specific medical error. Procedural Error 3 involved the heparin administered during the treatment. Overdosing of heparin could prove a problem for the patient and has been linked to fatalities in a variety of settings. The proper setting for heparin in this scenario would be 1.5 cc or mL per hour using 1000 units per 1 cc heparin. Heparin is actually supplied in the clinic studied in three dosage concentrations. The first is 1000 units per 1 cc, the second concentration is 5000 units per 1cc, and the third concentration is 10,000 units per 1 cc. The obvious differ-ences in dosages are dramatic; this could be a serious problem if not detected and corrected by the clini-cian. After this study was conducted, a policy change was made to pur-chase and utilize heparin only in the 1000 units per milliliter formulation. The reasons for this change were unrelated to the study. Procedural Error 4: Use of the wrong electrolyte concentrations for the patients prescribed dialy -sate. Earlier in Clinical Case 12, it states that the patient is ordered to have a 4K, 2.5 Ca dialysate. The dialysate of 4K has to be especially mixed for this patient. The solutions available in the wall outlets at this clinic are limited to two concentration selections of potassium solution levels of only either 2K or 3K. Therefore, if the dialysate is plugged into the wall as stated in Clinical Case 12, the potas-sium could only be at a concentration level of 2K or 3K, but not at a 4K level. This is a potentially significant medical error that can affect the car-diac muscle. Although outlet configu-rations and potassium concentrations could vary in specific clinical setups, the error here should be obvious to every practitioner, especially due to its potential injury severity to the sub-jects studied in the outpatient clinic study sites. The fourth procedural error in -volves connecting the dialysate to an improper potassium concentration solution. This could be a very serious error, and the consequences can range from tachycardia to bradycar-dia, myocardial infarction, heart attack, or even death. The blood maintains potassium levels within a narrow range normally between 3.5 and 5.0 mg/dL. Either a very high or excessively low serum potassium level could result in death to the patient. Procedural Error 5: The inser-tion of the needle direction into the fistula site. In Clinical Case 12, the fistula needle insertion states that the blue line is inserted below, and the red line is inserted above. This is reversed, and typically the blue or venous line is the upper needle in the fistula and the red or arterial line is referring to the lower or bottom needle insertion site. This configuration results in recirculation of the blood. The fifth and final procedural medical error embedded within Clin -ical Case 1 concerns the reversal of the direction of blood flow in the fis-tula by connecting the arterial line to the venous side of the fistula and the venous line to the arterial side of the fistula. This would result in recircula-tion of the blood flow, and there would be little or no dialysis occur-ring for the patient to remove waste products from the bloodstream and balance electrolytes. The outcome of this error is in the patient not receiv-ing the benefit of dialysis from the treatment while believing that the blood had been dialyzed properly. Clinical Case #2: Error Detection and Recovery There were two procedurally based errors in Clinical Case 2. Procedural Error 1: The charge nurse should have been called back immediately for help with a non-responsive patient. The first of the two embedded procedural patient care errors in Clinical Case # 2 was that the staff nurse should have called the charge nurse back right away when the non-responsive pa tient was discovered. This patient problem was serious enough that the charge nurse should have been notified without delay whether on a break or not. Within the specific clinical setting where the subject participants were tested, there was a telephone exten-sion that could have been used to call the charge nurse in the break room to return to the patient care unit right away. There was also an emergency alarm button that could have been pushed, which would have immedi-ately notified everyone in all of that clinics locations that the situation was Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 46 Error Recovery by Dialysis Technicians critical. When the emergency alarm is pressed everyone in the building responds. Procedural Error 2: The pa -tient should
