Table 3.

Expect the unexpected: Quality assurance planning

Event	What Happened	Medical Director Takeaway
Charleston, West Virginia chemical spill	A chemical spill in the Elk River contaminated the municipal water source, poisoning water for 300,000 residents and a number of dialysis clinics in the area (6)	Plan ahead; quality assurance plans should identify the dialysis clinic water source in case the municipal water becomes nonpotable
Lake Erie algal bloom	Algae blooms involving cyanobacteria (blue-green algae) have been known to contaminate public water with the hepatotoxin microcystin at levels five times the acceptable level (8)	Be alert; changes in source water can occur, creating chemical contamination that is not easily testable; quality assurance plans should include contingencies for diverse contamination scenarios
Water treatment system bacterial contamination	Fouling of a reverse osmosis membrane caused an epidemic of illness in 44 patients on hemodialysis, of whom two patients died; a sulfur-smelling odor was detected during water sampling from the reverse osmosis device (19)	Ask questions; any water room variable (appearance or odor) out of the ordinary may indicate a problem
Carbon filter failure	Patients receiving dialysis were exposed to chloramine-contaminated water caused by inadequate carbon filter dechlorination (20,21)	Test frequently; chloramine should be tested multiple times every day to protect patients from hemolysis associated with chlorine contamination of dialysis water
Municipal pipe repair	A change in a source water pipe caused aluminum contamination, subsequent aluminum intoxication, and possibly, hard water syndrome; 10 patients died (22)	Stay current; source water quality can change at any time