A new investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment.
Almost 30,000 people in the UK receive regular dialysis. The most common type of dialysis is haemodialysis, during which a patient’s blood goes through a tube into a machine to be filtered, and is then passed back into the patient’s body. To carry out haemodialysis, access is required to the bloodstream; one option for this is a vascular graft. This is a synthetic implant used to connect an artery and vein, to create a larger and stronger opening through which the blood can travel.
There are numerous types of vascular grafts produced by different manufacturers. Vascular grafts are available in different diameters and lengths, and may be either tapered or non-tapered in shape. Some vascular grafts are for delayed use, needing around 2 weeks between insertion and first use, and others are for rapid access and can be used approximately 72 hours after insertion.
This investigation used a real patient safety incident, referred to as ‘the reference event’, to examine aspects of the selection and insertion of vascular grafts, including measures to ensure the correct type is inserted. The reference event involved Teri, who had to undergo an additional procedure after the incorrect type of vascular graft was inserted for haemodialysis treatment.
The investigation’s findings, safety recommendations and safety observations aim to prevent the selection and insertion of incorrect vascular grafts from happening in the future and to improve care for patients across the NHS.
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Source: HSIB
Date: 7 August