P25
DEVELOPMENT OF A TRIGGER TOOL FOR AUDITING PATIENT HARM
DURING HAEMODIALYSIS
Fielding, C, Rhodes, C, Chesterton, L, Fluck, R, Lambe, G, Inacay, G, Taal, M
Department of Renal Medicine, Derby Hospitals NHS Foundation Trust
INTRODUCTION: Though life-sustaining, haemodialysis is associated with multiple potential
sources of harm to patients, yet this aspect of treatment has not previously been studied in
detail. Incident reporting usually focuses on episodes of severe harm but patient experience is
often adversely affected by less severe harm that may go unnoticed. We therefore aimed to
develop a tool to audit all types of harm specific to haemodialysis.
METHODS: A multidisciplinary team comprising haemodialysis nurses, nurse educators and
nephrology consultants compiled a comprehensive list of harms associated with haemodialysis.
We compared this list to the “Global Trigger Tool”, an audit tool developed by the Institute for
Health Improvement (US) to audit harm associated with healthcare. We subsequently developed
a “Haemodialysis Trigger Tool” (HTT) comprised of 5 domains containing a total of 40
triggers: General Care, Dialysis, Vascular Access, Medications and Laboratory Results. A pilot
audit was undertaken using the HTT to assess harm associated with 50 haemodialysis
treatments. Harm was defined as unintended physical injury or discomfort resulting from or
contributed to by medical care. Harm events were graded according to severity. Auditors were
asked to evaluate the audit tool for ease of use, time taken and ability to detect all harms.
RESULTS: The pilot audit found that 22 of 50 treatments (44%) were associated with at least 1
harm event. Overall the harm rate was 68 per 100 treatments. The most common harms
observed were symptomatic intradialytic hypotension (10/34 harm events) along with high
ultrafiltration rate (7/34 harm events). Most observed harms were graded minor, with only one
harm event requiring hospital admission. Staff found the HTT simple to use and each treatment
took less than 5 minutes to audit. The HTT did not fail to detect any dialysis associated harms.
CONCLUSION: We have developed a novel tool for auditing haemodialysis associated harm.
A pilot audit identified a high level of harm events associated with haemodialysis, though most
harms were minor. High ultrafiltration rates and hypotension during haemodialysis were the
most frequent harm events, indicating improvement initiatives should be focussed on fluid
assessment and fluid management. We propose to undertake a more comprehensive baseline
audit and to introduce the HTT for monthly monitoring of harm in our unit. We will feed back
the results of the monthly audits to the haemodialysis team, leading to practice development
focussed on observed harm events.
RELEVANCE: Identification of harm events to our patients will increase awareness of
haemodialysis-related harms and facilitate specific action to reduce harm. Development and
improvement projects on the unit can be focussed on observed harm events, rather than
assumptions made by healthcare teams and will in turn lead to reduced harm and improved
patient experience.