Predisposing factors |
|
Fall risk reduction |
100 |
The decrease in patients hospitalization rate |
40 |
The nursing team focus on patients and not on machines |
40 |
Do not eat during treatment |
20 |
Do not allow covering the patients' faces and access devices during treatment |
20 |
Event and near miss notification |
20 |
Volume overload reduction |
20 |
Use of personal protective equipment in patients with hepatitis B |
20 |
Disabling factors |
|
Vascular access infection |
100 |
Drug Errors |
80 |
Hypotension |
60 |
Vascular access thrombosis |
40 |
Shortened dialysis times |
40 |
Unexpected bleeding from vascular access |
40 |
Vascular access infiltration |
40 |
Failure to adhere to security procedures |
40 |
Non-compliance in the waste disposal |
20 |
Hypoglycemia |
20 |
Failure of patients to clean their access sites before HD starts |
20 |
Errors concerning dilution of the dialysis solution |
20 |
Needle disconnection |
20 |
Precipitating factors |
|
Provision of knowledge, skills, and guidance needed by the nursing team |
40 |
Effective communication during patient transfers and transitions in dialysis centers |
40 |
Time availability for the nursing staff |
20 |
Communication between nurses |
20 |
Participation of nurses in hospital management matters |
20 |
Provision of management support or monitoring of a reported event |
20 |
No real or perceived punishment for an employee reporting an event |
20 |
Analyze patient complaints |
20 |
Evaluation of vascular access before the puncture |
20 |
Sensitivity to patient complexity and complications |
20 |
Absence of heavy documentation systems |
20 |
Reinforcing factors |
|
Adequate staffing |
80 |
Provision of security policies, procedures, and guidelines |
60 |
Strong leadership practice of the nursing team |
40 |
Providing patient education |
40 |
Hand washing |
20 |
Wearing gloves |
20 |
Training of new employees |
20 |
Safety assessments during the patient transition |
20 |
Productive communication relationship between doctor and nurse |
20 |
Implementation of measures to adjust the prescription for patient hospitalization |
20 |
Proper patient flow management |
20 |
Monitoring and observation of nursing care |
20 |
Active devices to monitor patient safety risks |
20 |
Involving patients in their care |
20 |
Proper water treatment |
20 |
Monitoring of patient risk behaviors |
20 |
Monitoring and effective management of patients' demands to start and finish their HD treatments |
20 |
Proper teamwork |
20 |