Table 1.

Elements of ESRD patient safety improvement

1. Culture of safety: Create an environment in which it is safe to recognize and report errors for yourself and coworkers

Dialysis facilities should operate as high-reliability organizations

2. Regulatory protection: Create legislation and regulation protecting voluntary reporters of error

3. Human factors: Identify patterns of interaction at the machine-human interface that may predispose to error

4. Identify major causes of potentially reversible adverse outcomes

Medication errors

Infections

Access-related errors

Falls

Deaths from RRT complications

5. Perform root cause analyses of adverse events and “near misses”

6. Involve patients in safety efforts

7. Address home hemodialysis issues