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Enfermería Nefrológica

versão On-line ISSN 2255-3517versão impressa ISSN 2254-2884


GOMEZ LOPEZ, Victoria Eugenia et al. Analysis of corrective measures for reducing adverse events in a hospital dialysis unit. Enferm Nefrol [online]. 2019, vol.22, n.1, pp.27-33. ISSN 2255-3517.

Patients on hemodialysis (HD) are a population susceptible to suffering adverse events (AD) due to failures in the healthcare process.


To evaluate the efficacy of corrective measures in a HD patient safety plan to reduce AD.

Material and Method:

Descriptive and retrospective study of the HD records of a hospital unit. As an evaluation method, we used the methodology of our center (MIDEA) based on the Global Trigger Tools method.

All the HD sessions of March, May and July 2016 were reviewed: 2,080 sessions; and the same months in 2017: 1953 sessions.

After the 2016 analysis, the following corrective measures were implemented: revision of the anticoagulation procedure of the extracorporeal circuit, updating of the vascular access management and updating of the procedure before hypotension.


In 2016, the clinical records of 208 patients were reviewed. 255 EA were detected (11.8% of the sessions). The most frequent AEs were: 85 hypotension, 74 blood circuit coagulations, 31 vascular access problems and 65 other AD.

In 2017, the clinical records of 258 patients were reviewed. 155 AE were detected (in 7.9% of the sessions). The most frequent AEs were: 60 hypotension, 36 circuit coagulations, 30 vascular access problems and 29 other AE.


Adverse events decreased by 39.2% in 2017, and although hypotension, blood circuit coagulation and vascular access problems are the most frequent, we consider that corrective measures are being effective.

Palavras-chave : safety; hemodialysis; adverse event.

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