Dialysis Nursing Expert Comments on Patient Death During Treatment in Outpatient Dialysis Center

Case Overview

This case involves an elderly male patient who died while receiving treatment at a dialysis center. The patient presented to the dialysis center with an elevated heart rate and a prescription for antibiotics, which was suggestive of an active infection for which he was receiving treatment. He was not seen by his physician on arrival to the dialysis facility and, as a result, the physician did not evaluate his physical condition before dialysis treatment was begun. At some point while he was receiving treatment the patient went into cardiac arrest. Neither the physician nor any of the other personnel at the treatment center checked on the patient during the time he was there receiving treatment, which took several hours. Additionally, the patient’s vital signs were not monitored during the treatment. Staff at the dialysis center only discovered that the patient had died hours after he had begun treatment. It was alleged that the facility failed to adequately evaluate the patient’s condition, both during his arrival at the facility and during his dialysis treatment.

Questions to the Nephrology expert and their responses

Do you see patients in a dialysis center on a routine basis?

I frequently see dialysis patients in treatment centers on a routine basis.

Given the condition of this patient, should a physician and/or a nursing staff member have evaluated him before beginning treatment?

It is critical that patients should be assessed before each and every treatment.

If a patient presents to the dialysis center with a severely elevated heart rate and signs of infection, should he be sent to the emergency room?

Blood work should have been drawn, and the patient should have been sent to the ER following assessment and orders from the physician if conditions remained the same. The patient in this case appears to have been unstable when he arrived at the center.

What additional monitoring procedures during dialysis treatment must be adhered to?

Monitoring of patients is continuous throughout treatment, and documentation of such is required at a minimum of every 30 minutes. For unstable patients, this is done more frequently. It is clear that there was a major failure to adequately monitor the patient's condition in this case.

About the expert

This expert has been a practicing nurse for 20 years. She holds membership in the American Nephrology Nurses' Association, the American Nurses Association, as well as the National Kidney Foundation, and she is the current President of her local National Nephrology Nurses Association chapter. Since May 2008, this expert has been the Director of Nursing at an outpatient dialysis center, where she oversees the renal program, ensures compliance with all regulatory agencies, and incorporates Nephrology Nursing Standards of Care into the practice. She is also currently an Adjunct Faculty at a major technical college, where she teaches a Hemodialysis Technician course.

E-007297

Specialties:

Nephrology